Healthcare Provider Details

I. General information

NPI: 1902107345
Provider Name (Legal Business Name): SOUTH LOUP COMMUNITY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PACIFIC ST
CALLAWAY NE
68825-2500
US

IV. Provider business mailing address

200 E PACIFIC ST P.O. BOX 220
CALLAWAY NE
68825-2500
US

V. Phone/Fax

Practice location:
  • Phone: 308-836-2219
  • Fax: 308-836-2625
Mailing address:
  • Phone: 308-836-2219
  • Fax: 308-836-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2897
License Number StateNE

VIII. Authorized Official

Name: BRETT D EGGLESTON
Title or Position: CEO
Credential:
Phone: 308-836-2228