1003943176 NPI number — LJC,INC DBA STONE DRUG

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003943176 NPI number — LJC,INC DBA STONE DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LJC,INC DBA STONE DRUG
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:
Provider Other Organization Name Type Code:
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:
1003943176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9000
Provider Second Line Business Mailing Address:
830 WEST BROADWAY
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83002-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-733-9768
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 WEST BROADWAY
Provider Second Line Business Practice Location Address:
BOX 9000
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-733-9768
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CROOK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
FISHER
Authorized Official Title or Position:
PRESIDENT, PIC
Authorized Official Telephone Number:
307-733-9768

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  52-02356 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 52-02356 . This is a "WY RETAIL PHARMACY LICENS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 1500 . This is a "WY WHOLESALER-DISTRIBUTER" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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