Healthcare Provider Details

I. General information

NPI: 1174520332
Provider Name (Legal Business Name): CROSIER PARK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E 14TH ST
HASTINGS NE
68901-3204
US

IV. Provider business mailing address

405 E 14TH ST
HASTINGS NE
68901-3204
US

V. Phone/Fax

Practice location:
  • Phone: 402-462-4600
  • Fax: 402-462-4605
Mailing address:
  • Phone: 402-462-4600
  • Fax: 402-462-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number190
License Number StateNE

VIII. Authorized Official

Name: DR. SCOTT A KIRKEGAARD
Title or Position: OWNER
Credential: PHARM.D., BCPP
Phone: 402-462-4600