1588042816 NPI number — MAIN SAIL ENTERPRISES-DOWNTOWN LLC

Table of content: (NPI 1588042816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588042816 NPI number — MAIN SAIL ENTERPRISES-DOWNTOWN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN SAIL ENTERPRISES-DOWNTOWN 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:
DBA DOWNTOWN PHARMACY
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:
1588042816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 W CHESTERFIELD BLVD
Provider Second Line Business Mailing Address:
SUITE C100-125
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65807-6946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-343-0635
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 S CAMPBELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65806-2901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-343-0635
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KERR
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
417-343-0635

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2015012288 , 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)





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