MEDICARE: SKAGWAY DISC DEPT. STORES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	2113	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2813942	OTHER	NE	NCPDP OR NABP NO.

General Provider Information

NPI Number	:	1679615819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKAGWAY DISC DEPT. STORES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1647
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68802-1647
Country	:	US
Telephone Number	:	308-384-9120
Fax Number	:	308-398-9021

Provider Business Practice Location Address
First Line	:	1607 S LOCUST ST
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68801-8246
Country	:	US
Telephone Number	:	308-384-9120
Fax Number	:	308-398-9021

Authorized Official
Title or Position	:	SECRETARY
Name	:	MR. TIM W BOLTON
Credential	:
Telephone Number	:	308-384-8222

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	08/22/2020

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