1902169816 NPI number — BADGER HEALTH CORP

Table of content: (NPI 1902169816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902169816 NPI number — BADGER HEALTH CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BADGER HEALTH CORP
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:
THE MEDICINE SHOPPE 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:
1902169816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 S 2ND ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RATON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87740-2209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-445-0075
Provider Business Mailing Address Fax Number:
575-445-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 S 2ND ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-445-0075
Provider Business Practice Location Address Fax Number:
575-445-0081
Provider Enumeration Date:
06/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SCHEELS
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY/OWNER
Authorized Official Telephone Number:
303-898-7183

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PH00003416 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2137565 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 69856745 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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