1740315076 NPI number — ROADRUNNER APOTHECARY, LLC

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 1740315076 NPI number — ROADRUNNER APOTHECARY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROADRUNNER APOTHECARY, 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:
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:
1740315076
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 11005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83002-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-732-0540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 GREGORY LANE UNIT A3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-732-0540
Provider Business Practice Location Address Fax Number:
307-732-0541
Provider Enumeration Date:
02/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MELKA
Authorized Official First Name:
BABETTE
Authorized Official Middle Name:
EPPLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-732-0540

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  2869 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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