1679615819 NPI number — SKAGWAY DISC DEPT. STORES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679615819 NPI number — SKAGWAY DISC DEPT. STORES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKAGWAY DISC DEPT. STORES, 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:
SKAGWAY PHARMACY # 2
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:
1679615819
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:
PO BOX 1647
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68802-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-9120
Provider Business Mailing Address Fax Number:
308-398-9021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1607 S LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68801-8246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-384-9120
Provider Business Practice Location Address Fax Number:
308-398-9021
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOLTON
Authorized Official First Name:
TIM
Authorized Official Middle Name:
W
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
308-384-8222

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2113 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2813942 . This is a "NCPDP OR NABP NO." identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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