1750673919 NPI number — RESTORE HEALTH PHARMACY, LLC

Table of content: NICHOLAS RAY MCSWEEN RN (NPI 1427377084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750673919 NPI number — RESTORE HEALTH PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORE HEALTH PHARMACY, 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:
6
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:
1750673919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1289 DEMING WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53717-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-558-7046
Provider Business Mailing Address Fax Number:
888-898-7412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1289 DEMING WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53717-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-558-7046
Provider Business Practice Location Address Fax Number:
888-898-7412
Provider Enumeration Date:
05/06/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WANDERER
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
480-421-8005

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 9070-042 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2130190 . This is a "PK" identifier . This identifiers is of the category "OTHER".