Healthcare Provider Details

I. General information

NPI: 1720154826
Provider Name (Legal Business Name): THREE AMIGOS APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MAPLE ST STE B
CHERRYVALE KS
67335-1729
US

IV. Provider business mailing address

116 N MAPLE ST STE B
CHERRYVALE KS
67335-1729
US

V. Phone/Fax

Practice location:
  • Phone: 620-336-2144
  • Fax: 620-336-3285
Mailing address:
  • Phone: 620-336-2144
  • Fax: 620-336-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-10407
License Number StateKS

VIII. Authorized Official

Name: BRIAN CASWELL
Title or Position: PRESIDENT PHARMACIST IN CHARGE
Credential:
Phone: 620-674-2018