1558364141 NPI number — HODGINS DRUG STORE, INC.

Table of content: (NPI 1558364141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558364141 NPI number — HODGINS DRUG STORE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HODGINS DRUG STORE, 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:
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:
1558364141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-882-5536
Provider Business Mailing Address Fax Number:
208-882-4741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-5536
Provider Business Practice Location Address Fax Number:
208-882-4741
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAYS
Authorized Official First Name:
PAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-882-5536

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  065CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332S00000X , with the licence number: H244 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 065CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: 065CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 70011 . This is a "BLUE CROSS OF IDAHO RX" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 6013833 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010014112 . This is a "REGENCE BLUE SHIELD DME" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002302500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805459300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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