Provider Demographics
NPI:1366568628
Name:MDDC, INC
Entity type:Organization
Organization Name:MDDC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:913-845-8436
Mailing Address - Street 1:1701 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-5369
Mailing Address - Country:US
Mailing Address - Phone:913-845-8436
Mailing Address - Fax:
Practice Address - Street 1:1701 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-5369
Practice Address - Country:US
Practice Address - Phone:913-845-8436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-096963336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS60 874111 01Medicaid