Healthcare Provider Details

I. General information

NPI: 1013460922
Provider Name (Legal Business Name): HODGEMAN COUNTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MAIN STREET
JETMORE KS
67854
US

IV. Provider business mailing address

PO BOX 782
CIMARRON KS
67835-0782
US

V. Phone/Fax

Practice location:
  • Phone: 620-357-8305
  • Fax: 620-855-2052
Mailing address:
  • Phone: 620-855-2055
  • Fax: 620-855-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2-100543
License Number StateKS

VIII. Authorized Official

Name: JAMES COAST
Title or Position: RPH
Credential:
Phone: 620-855-2055