1558790410 NPI number — BAKER DRUG LLC

Table of content: (NPI 1558790410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558790410 NPI number — BAKER DRUG LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAKER DRUG LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STAR PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558790410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 56
Provider Second Line Business Mailing Address:
118 E. ROLLA STREET
Provider Business Mailing Address City Name:
HARTVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65667-0056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-741-6266
Provider Business Mailing Address Fax Number:
417-741-1616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E. ROLLA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65667-0056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-741-6266
Provider Business Practice Location Address Fax Number:
417-741-1616
Provider Enumeration Date:
11/01/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
GAROLD
Authorized Official Middle Name:
Authorized Official Title or Position:
R,PH
Authorized Official Telephone Number:
417-741-6266

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  2005039922 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)