Healthcare Provider Details

I. General information

NPI: 1447265863
Provider Name (Legal Business Name): MDSLC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MAIN ST
GORDON NE
69343-1524
US

IV. Provider business mailing address

116 N MAIN ST
GORDON NE
69343-1524
US

V. Phone/Fax

Practice location:
  • Phone: 308-282-1114
  • Fax: 308-282-2250
Mailing address:
  • Phone: 308-282-1114
  • Fax: 308-282-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3021
License Number StateNE

VIII. Authorized Official

Name: MICHAEL COOKSTON
Title or Position: OWNER/PRESIDENT/PIC/AO
Credential:
Phone: 308-282-1114