Healthcare Provider Details

I. General information

NPI: 1811050669
Provider Name (Legal Business Name): BLOODHART DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S MAIN ST
HUGOTON KS
67951-2419
US

IV. Provider business mailing address

PO BOX 6680
LEES SUMMIT MO
64064-6680
US

V. Phone/Fax

Practice location:
  • Phone: 620-544-4369
  • Fax: 620-544-7045
Mailing address:
  • Phone: 816-777-0609
  • Fax: 816-777-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number004300246227F01
License Number StateKS

VIII. Authorized Official

Name: MR. ROBERT WINTERS
Title or Position: VICE PRESIDENT
Credential:
Phone: 816-777-0609