1639232390 NPI number — KINGSWAY ENT. INC

Table of content: (NPI 1639232390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639232390 NPI number — KINGSWAY ENT. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSWAY ENT. INC
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:
KINGSWAY 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:
1639232390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1677 MONTGOMERY RD
Provider Second Line Business Mailing Address:
SUITE 110-112
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-8802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-236-9502
Provider Business Mailing Address Fax Number:
630-236-9512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1677 MONTGOMERY RD
Provider Second Line Business Practice Location Address:
SUITE 110-112
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-8802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-236-9502
Provider Business Practice Location Address Fax Number:
630-236-9512
Provider Enumeration Date:
12/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NIMAKO-BOATENG
Authorized Official First Name:
RICHMOND
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-236-9502

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  054015027 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054015027 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: 054015027 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1476426 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".