Healthcare Provider Details

I. General information

NPI: 1104873769
Provider Name (Legal Business Name): MEDICAL PHARMACY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 COLUMBINE DR
HOLTON KS
66436-8841
US

IV. Provider business mailing address

PO BOX 9830
SALT LAKE CITY UT
84109-9830
US

V. Phone/Fax

Practice location:
  • Phone: 785-364-2114
  • Fax: 785-364-4501
Mailing address:
  • Phone: 877-540-4748
  • Fax: 801-716-4824

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 Number2-10232
License Number StateKS

VIII. Authorized Official

Name: JOSEPH GILLILAND
Title or Position: OWNER
Credential:
Phone: 785-364-2114