1083016679 NPI number — WEIMER DRUG STORE, INC

Table of content: (NPI 1083016679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083016679 NPI number — WEIMER DRUG STORE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEIMER 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:
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:
1083016679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
685 LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-825-0778
Provider Business Mailing Address Fax Number:
785-827-7415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
685 LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-825-0778
Provider Business Practice Location Address Fax Number:
785-827-7415
Provider Enumeration Date:
09/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GRUEN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PIC AND MANAGER
Authorized Official Telephone Number:
785-825-0778

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2-13047 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 2-13047 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2-13047 . This is a "KANSAS STATE PHARMACY LISCENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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