1447345525 NPI number — EVANS DRUGS NEVADA LLC

Table of content: (NPI 1447345525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447345525 NPI number — EVANS DRUGS NEVADA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANS DRUGS NEVADA LLC
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:
WOODS PHARMACY
Provider Other Organization Name Type Code:
4
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:
1447345525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 E US HIGHWAY 54
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64744-1925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-876-3313
Provider Business Mailing Address Fax Number:
417-876-2326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 W AUSTIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEVADA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64772-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-667-3953
Provider Business Practice Location Address Fax Number:
417-448-5991
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TIMMERMANN
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
417-876-3313

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  240468217 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 606032902 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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