Healthcare Provider Details

I. General information

NPI: 1487727293
Provider Name (Legal Business Name): FOUR STAR DRUG OF WAVERLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 GUILDFORD ST SUITE D
WAVERLY NE
68462
US

IV. Provider business mailing address

13851 GUILDFORD ST SUITE D
WAVERLY NE
68462
US

V. Phone/Fax

Practice location:
  • Phone: 402-786-2222
  • Fax: 402-786-2502
Mailing address:
  • Phone: 402-786-2222
  • Fax: 402-786-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number278
License Number StateNE

VIII. Authorized Official

Name: DR. MONTY LEE SCHEELE
Title or Position: DIRECTOR OF PHARMACY OPERATIONS
Credential: PHARM.D.
Phone: 402-434-7701