1861645509 NPI number — PRESCRIPTION DRUG STORE

Table of content: (NPI 1861645509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861645509 NPI number — PRESCRIPTION DRUG STORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESCRIPTION DRUG STORE
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:
PRESCRIPTION DRUG STORE
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:
1861645509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYTI
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63851-1639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-359-0008
Provider Business Mailing Address Fax Number:
573-359-6376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYTI
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63851-1639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-359-0008
Provider Business Practice Location Address Fax Number:
573-359-6376
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUDLEY
Authorized Official First Name:
SHANE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-333-4890

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 620126110 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com