1922160605 NPI number — NATIONAL DRUG STORE INC

Table of content: (NPI 1922160605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922160605 NPI number — NATIONAL DRUG STORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONAL DRUG STORE 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:
LYNN'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:
1922160605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 W NATIONAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAZIL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47834-2537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-446-2381
Provider Business Mailing Address Fax Number:
812-448-1855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 W NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAZIL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47834-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-446-2381
Provider Business Practice Location Address Fax Number:
812-448-1855
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOSTETLER
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
DUANE
Authorized Official Title or Position:
CEO, OWNER
Authorized Official Telephone Number:
812-446-2381

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  600001656A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 60001656A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100294490 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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