Healthcare Provider Details

I. General information

NPI: 1619966272
Provider Name (Legal Business Name): PRESCRIPTION SHOP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 11TH ST
COFFEYVILLE KS
67337-5025
US

IV. Provider business mailing address

601 W 11TH ST
COFFEYVILLE KS
67337-5025
US

V. Phone/Fax

Practice location:
  • Phone: 620-251-1620
  • Fax: 620-251-4730
Mailing address:
  • Phone: 620-251-1620
  • Fax: 620-251-4730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number209131
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALAN DEFEVER
Title or Position: OWNER
Credential: RPH
Phone: 913-515-0462