1053854018 NPI number — SPRINGFIELDDRUG

Table of content: (NPI 1053854018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053854018 NPI number — SPRINGFIELDDRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRINGFIELDDRUG
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:
1053854018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68059-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-253-2000
Provider Business Mailing Address Fax Number:
402-253-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68059-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-253-2000
Provider Business Practice Location Address Fax Number:
402-253-2001
Provider Enumeration Date:
11/23/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HENTZEN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
RONALD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-253-2000

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  8552 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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