1104257658 NPI number — MAIN STREET PHARMACY I CORP

Table of content: (NPI 1104257658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104257658 NPI number — MAIN STREET PHARMACY I CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET PHARMACY I 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:
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:
1104257658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
389 S MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 120
Provider Business Mailing Address City Name:
FREEMAN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57029-2337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-925-7059
Provider Business Mailing Address Fax Number:
605-925-7360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57043-2058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-648-3751
Provider Business Practice Location Address Fax Number:
605-648-3179
Provider Enumeration Date:
12/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KAUFMAN
Authorized Official First Name:
NORM
Authorized Official Middle Name:
Authorized Official Title or Position:
CORP. PRES
Authorized Official Telephone Number:
605-925-7059

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  100-1825 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2143318 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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