1194828194 NPI number — PHARMACON DRUG

Table of content: (NPI 1194828194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194828194 NPI number — PHARMACON DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACON 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:
DERBY 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:
1194828194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 N ROCK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DERBY
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67037-3735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-788-6669
Provider Business Mailing Address Fax Number:
316-788-3570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 N ROCK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERBY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67037-3735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-788-6669
Provider Business Practice Location Address Fax Number:
316-788-3570
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAMM
Authorized Official First Name:
GARY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
316-788-5533

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  7934 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100437990A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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