1578542924 NPI number — ARCADIA VALLEY DRUG ACQUISITION CO

Table of content: (NPI 1578542924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578542924 NPI number — ARCADIA VALLEY DRUG ACQUISITION CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARCADIA VALLEY DRUG ACQUISITION CO
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:
1578542924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7645 E 63RD ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74133-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-858-4619
Provider Business Mailing Address Fax Number:
918-592-4585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRONTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63650-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-756-1024
Provider Business Practice Location Address Fax Number:
573-747-0444
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEAVENY
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTING MANAGER
Authorized Official Telephone Number:
612-227-7811

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2005013885 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 2005013885 , 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: 620054304 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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