=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164845640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SABETHA APOTHECARY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2014
-----------------------------------------------------
Last Update Date | 02/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 MAIN ST
-----------------------------------------------------
City | SABETHA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66534-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-300-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 MAIN ST
-----------------------------------------------------
City | SABETHA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66534-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-300-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LEA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 785-300-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 2-10412
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------