1689065856 NPI number — SUTTON DRUGS OF LA CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689065856 NPI number — SUTTON DRUGS OF LA CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUTTON DRUGS OF LA CENTER 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:
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:
1689065856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CENTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42056-0179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-665-5192
Provider Business Mailing Address Fax Number:
270-665-9296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CENTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-665-5192
Provider Business Practice Location Address Fax Number:
270-665-9296
Provider Enumeration Date:
02/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RENFROW
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
270-665-5192

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  P01069 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54014162 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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