Provider Demographics
NPI:1194898197
Name:FOUR STAR DRUG OF BETHANY INC
Entity type:Organization
Organization Name:FOUR STAR DRUG OF BETHANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCHEELE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:402-434-7701
Mailing Address - Street 1:1340 N 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-1822
Mailing Address - Country:US
Mailing Address - Phone:402-434-7701
Mailing Address - Fax:402-434-7744
Practice Address - Street 1:1340 N 66TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-1822
Practice Address - Country:US
Practice Address - Phone:402-434-7701
Practice Address - Fax:402-434-7744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid