Provider Demographics
NPI:1154306165
Name:SERVICE DRUG, INC
Entity type:Organization
Organization Name:SERVICE DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:308-432-2400
Mailing Address - Street 1:302 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-2395
Mailing Address - Country:US
Mailing Address - Phone:308-432-2400
Mailing Address - Fax:308-432-6759
Practice Address - Street 1:302 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337
Practice Address - Country:US
Practice Address - Phone:308-432-2400
Practice Address - Fax:308-432-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NE13103336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36853OtherBC/BS OF NE
NE=========00Medicaid
NE0344460001Medicare ID - Type Unspecified