1861679771 NPI number — JOHN'S RX DRUG, INC

Table of content: (NPI 1861679771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861679771 NPI number — JOHN'S RX DRUG, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN'S RX DRUG, 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:
JOHN'S RX DRUG
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:
1861679771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRACY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56175-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-629-3801
Provider Business Mailing Address Fax Number:
507-629-4694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56175-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-629-3801
Provider Business Practice Location Address Fax Number:
507-629-4694
Provider Enumeration Date:
01/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCHLEPPENBACH-GROGAN
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
507-629-3801

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  201215 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 401360300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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