Provider Demographics
NPI:1104896752
Name:DUESTERBERG DRUG CO INC
Entity type:Organization
Organization Name:DUESTERBERG DRUG CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:812-882-6193
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-0116
Mailing Address - Country:US
Mailing Address - Phone:812-882-6193
Mailing Address - Fax:812-882-6186
Practice Address - Street 1:402 S 6TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1023
Practice Address - Country:US
Practice Address - Phone:812-882-6193
Practice Address - Fax:812-882-6186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60000728A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100309350Medicaid
1514454OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0720570001Medicare NSC