1730225343 NPI number — DAILEYS CLINIC PHCY INC

Table of content: (NPI 1730225343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730225343 NPI number — DAILEYS CLINIC PHCY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAILEYS CLINIC PHCY 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:
COLEMAN CLINIC 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:
1730225343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
735 W 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAHOO
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68066-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
735 W 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAHOO
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68066-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-443-3979
Provider Business Practice Location Address Fax Number:
402-443-5527
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LORENZ
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND PIC
Authorized Official Telephone Number:
402-443-3979

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2196 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2814398 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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