1932241700 NPI number — ENNIS PHARMACY AND YESTERDAY'S SODA FOUNTAIN, INC

Table of content: (NPI 1932241700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932241700 NPI number — ENNIS PHARMACY AND YESTERDAY'S SODA FOUNTAIN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENNIS PHARMACY AND YESTERDAY'S SODA FOUNTAIN, 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:
ENNIS HEALTH MART 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:
1932241700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
124 EAST MAIN STREET
Provider Business Mailing Address City Name:
ENNIS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59729-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-682-4246
Provider Business Mailing Address Fax Number:
406-682-7568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENNIS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59729-0306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-682-4246
Provider Business Practice Location Address Fax Number:
406-682-7568
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CROY
Authorized Official First Name:
STACY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHARMACY TECHNICIAN/OWNER
Authorized Official Telephone Number:
406-682-4246

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  807 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 221377 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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