Healthcare Provider Details

I. General information

NPI: 1003914615
Provider Name (Legal Business Name): HOMETOWN DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 BROADWAY
IMPERIAL NE
69033-0597
US

IV. Provider business mailing address

1324 BROADWAY; PO BOX 597
IMPERIAL NE
69033-0597
US

V. Phone/Fax

Practice location:
  • Phone: 308-882-4863
  • Fax: 308-882-4510
Mailing address:
  • Phone: 308-882-4863
  • Fax: 308-882-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2686
License Number StateNE

VIII. Authorized Official

Name: DIANE SANDALL
Title or Position: CO-OWNER
Credential:
Phone: 308-882-4863