Healthcare Provider Details

I. General information

NPI: 1083614697
Provider Name (Legal Business Name): PALACE DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N FRANKLIN AVE
COLBY KS
67701-2326
US

IV. Provider business mailing address

460 N FRANKLIN AVE
COLBY KS
67701-2326
US

V. Phone/Fax

Practice location:
  • Phone: 785-460-7507
  • Fax: 785-460-2522
Mailing address:
  • Phone: 785-460-7507
  • Fax: 785-460-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-06543
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number2-06543
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number206543
License Number StateKS

VIII. Authorized Official

Name: MR. RANDALL DUANE SMITH
Title or Position: PHARMACIST/OWNER
Credential: RPH.
Phone: 785-460-7507