1619015609 NPI number — RED CROSS PHARMACY, INC

Table of content: (NPI 1619015609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619015609 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:
1619015609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2012
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:
401 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64012-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-892-1200
Provider Business Practice Location Address Fax Number:
816-331-2400
Provider Enumeration Date:
02/02/2007

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
Authorized Official Telephone Number:
660-886-5535

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 000792 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2603125 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2603125 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 600057707 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 620057711 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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