Provider Demographics
NPI:1306304928
Name:HODGEMAN COUNTY PHARMACY LLC
Entity type:Organization
Organization Name:HODGEMAN COUNTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-855-0095
Mailing Address - Street 1:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-0782
Mailing Address - Country:US
Mailing Address - Phone:620-855-2055
Mailing Address - Fax:620-855-2052
Practice Address - Street 1:519 MAIN ST
Practice Address - Street 2:
Practice Address - City:JETMORE
Practice Address - State:KS
Practice Address - Zip Code:67854-0068
Practice Address - Country:US
Practice Address - Phone:620-357-8305
Practice Address - Fax:620-357-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1013460922OtherNPI
KS201138190AMedicaid