Healthcare Provider Details

I. General information

NPI: 1740291558
Provider Name (Legal Business Name): GOTHENBURG DISCOUNT PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 AVENUE D STE 102
GOTHENBURG NE
69138-1955
US

IV. Provider business mailing address

PO BOX 159
GOTHENBURG NE
69138-0159
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-7155
  • Fax: 308-537-7366
Mailing address:
  • Phone: 308-537-7155
  • Fax: 308-537-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3060
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3060
License Number StateNE

VIII. Authorized Official

Name: MR. DANIEL DUANE KREIS
Title or Position: PRESIDENT
Credential: R.P.
Phone: 308-537-7155