Provider Demographics
NPI:1699866202
Name:CENTRE PHARMACY, INC.
Entity type:Organization
Organization Name:CENTRE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC OWNER,MGR.
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:785-282-6933
Mailing Address - Street 1:114 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SMITH CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:66967-2606
Mailing Address - Country:US
Mailing Address - Phone:785-282-6933
Mailing Address - Fax:785-282-3550
Practice Address - Street 1:114 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITH CENTER
Practice Address - State:KS
Practice Address - Zip Code:66967-2606
Practice Address - Country:US
Practice Address - Phone:785-282-6933
Practice Address - Fax:785-282-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS332B00000X
KS2-070233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100443860AMedicaid
KS100443860AMedicaid