Healthcare Provider Details

I. General information

NPI: 1063573178
Provider Name (Legal Business Name): JEFFREY L MENZIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 N MAIN ST
ULYSSES KS
67880-2130
US

IV. Provider business mailing address

PO BOX 925
ULYSSES KS
67880-0925
US

V. Phone/Fax

Practice location:
  • Phone: 620-356-1446
  • Fax: 620-356-5381
Mailing address:
  • Phone: 620-356-1446
  • Fax: 620-356-5381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number206795
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY MENZIE
Title or Position: OWNER
Credential: RPH
Phone: 620-356-1446