Healthcare Provider Details

I. General information

NPI: 1083629695
Provider Name (Legal Business Name): GOODLAND MEDICAL ARTS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WILLOW RD
GOODLAND KS
67735-1520
US

IV. Provider business mailing address

202 WILLOW RD
GOODLAND KS
67735-1520
US

V. Phone/Fax

Practice location:
  • Phone: 785-890-5111
  • Fax: 785-890-5111
Mailing address:
  • Phone: 785-890-5111
  • Fax: 785-890-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-09423
License Number StateKS

VIII. Authorized Official

Name: CESAR MILLER
Title or Position: PHARMACY MANAGER
Credential:
Phone: 785-890-5111