Provider Demographics
NPI:1487727293
Name:FOUR STAR DRUG OF WAVERLY
Entity type:Organization
Organization Name:FOUR STAR DRUG OF WAVERLY
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 1:13851 GUILDFORD ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:WAVERLY
Mailing Address - State:NE
Mailing Address - Zip Code:68462
Mailing Address - Country:US
Mailing Address - Phone:402-786-2222
Mailing Address - Fax:402-786-2502
Practice Address - Street 1:13851 GUILDFORD ST
Practice Address - Street 2:SUITE D
Practice Address - City:WAVERLY
Practice Address - State:NE
Practice Address - Zip Code:68462
Practice Address - Country:US
Practice Address - Phone:402-786-2222
Practice Address - Fax:402-786-2502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR STAR DRUG OF BETHANY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47607128202Medicaid