Healthcare Provider Details

I. General information

NPI: 1073539235
Provider Name (Legal Business Name): PORTER DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 MAIN ST
NEODESHA KS
66757-1739
US

IV. Provider business mailing address

506 MAIN ST
NEODESHA KS
66757-1739
US

V. Phone/Fax

Practice location:
  • Phone: 620-325-2671
  • Fax:
Mailing address:
  • Phone: 620-325-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2-04548
License Number StateKS

VIII. Authorized Official

Name: MR. PATRICK PORTER
Title or Position: PHARMACIST IN CHARGE/OWNER
Credential:
Phone: 620-325-2671