1790735405 NPI number — LOUDERBACK DRUG OF SPOKANE INC.

Table of content: (NPI 1790735405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790735405 NPI number — LOUDERBACK DRUG OF SPOKANE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUDERBACK DRUG OF SPOKANE 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:
PLATTER'S 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:
1790735405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8055 O ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68510-2564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-489-1135
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 E 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-1334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-838-3588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOUDERBACK
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-489-1135

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  CF00056874 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6024319 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9054495 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".