Healthcare Provider Details

I. General information

NPI: 1821189366
Provider Name (Legal Business Name): EBY DRUG STORE (LOGAN), INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N 4TH AVE
LOGAN IA
51546
US

IV. Provider business mailing address

103 N 4TH AVE P.O. BOX 187
LOGAN IA
51546
US

V. Phone/Fax

Practice location:
  • Phone: 712-644-2160
  • Fax: 712-644-2103
Mailing address:
  • Phone: 712-644-2160
  • Fax: 712-644-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number603
License Number StateIA

VIII. Authorized Official

Name: STEPHEN P. EBY
Title or Position: PRESIDENT
Credential:
Phone: 712-644-2848