1023173796 NPI number — STATELINE DRUG INC

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 1023173796 NPI number — STATELINE DRUG INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATELINE 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:
Provider Other Organization Name Type Code:
6
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:
1023173796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MAIN AVE
Provider Second Line Business Mailing Address:
BOX 360
Provider Business Mailing Address City Name:
LEMMON
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57638-1419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-374-3897
Provider Business Mailing Address Fax Number:
605-374-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MAIN AVE
Provider Second Line Business Practice Location Address:
BOX 360
Provider Business Practice Location Address City Name:
LEMMON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57638-1419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-374-3897
Provider Business Practice Location Address Fax Number:
605-374-5510
Provider Enumeration Date:
12/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SONSALLA
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
605-374-3897

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: 100-0056 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8501362 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020209 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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