1306891734 NPI number — RED CROSS PHARMACY, INC

Table of content: (NPI 1306891734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306891734 NPI number — RED CROSS PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED CROSS PHARMACY, 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:
1306891734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65340-0917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-886-5535
Provider Business Mailing Address Fax Number:
660-886-6320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1712 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGGINSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64037-1345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-584-2110
Provider Business Practice Location Address Fax Number:
660-584-5589
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTWIG
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CO-PRESIDENT/CEO (OWNER)
Authorized Official Telephone Number:
660-886-5535

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2007033676 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 2007033675 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 605194307 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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