1811050669 NPI number — BLOODHART DRUG LLC

Table of content: (NPI 1811050669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811050669 NPI number — BLOODHART DRUG LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOODHART 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:
WINTERS PHARMACIES
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:
1811050669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6680
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64064-6680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-777-0609
Provider Business Mailing Address Fax Number:
816-777-0615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUGOTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67951-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-544-4369
Provider Business Practice Location Address Fax Number:
620-544-7045
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINTERS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
816-777-0609

Provider Taxonomy Codes

  • Taxonomy code: 183700000X , with the licence number:  004300246227F01 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200118220-A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200452510-B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200452510-A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203043087 . This is a "LANSING PHARMACY" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 118383 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 203303814 . This is a "KOHLER PROFESSIONAL PHARM" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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