1427489467 NPI number — WEST JEFFERSON DRUGGIST LLC

Table of content: (NPI 1427489467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427489467 NPI number — WEST JEFFERSON DRUGGIST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST JEFFERSON DRUGGIST LLC
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:
HAPPY DRUGGIST PHARMACY-WJD
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:
1427489467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAIN CITY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43064-0126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-573-1557
Provider Business Mailing Address Fax Number:
614-300-7558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
487 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST JEFFERSON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43162-1178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-879-8500
Provider Business Practice Location Address Fax Number:
614-879-6171
Provider Enumeration Date:
12/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CRAFT
Authorized Official First Name:
LONNIE
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
614-573-1557

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: RTP02238560003 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0109253 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2147441 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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