1790885770 NPI number — REDLERS PROFESSIONAL PHARMACY 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 1790885770 NPI number — REDLERS PROFESSIONAL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDLERS PROFESSIONAL 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:
1790885770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 W 29TH ST
Provider Second Line Business Mailing Address:
STE 208
Provider Business Mailing Address City Name:
S SIOUX CITY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 W 29TH ST
Provider Second Line Business Practice Location Address:
STE 208
Provider Business Practice Location Address City Name:
S SIOUX CITY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-494-5542
Provider Business Practice Location Address Fax Number:
402-494-2207
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REDLER
Authorized Official First Name:
LOWELL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-494-5542

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  1408 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2804741 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2804741 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0970814 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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