1376628396 NPI number — VAN'S CORNER DRUG

Table of content: (NPI 1376628396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376628396 NPI number — VAN'S CORNER DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VAN'S CORNER 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:
1376628396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUPUN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53963-2161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-324-5211
Provider Business Mailing Address Fax Number:
920-324-4360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUPUN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53963-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-324-5211
Provider Business Practice Location Address Fax Number:
920-324-4360
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANDELIST
Authorized Official First Name:
MARK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
920-324-5211

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  7714-042 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5114373 . This is a "NCPDP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 33226400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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