Provider Demographics
NPI:1992078117
Name:THREE AMIGOS APOTHACARY LLC
Entity type:Organization
Organization Name:THREE AMIGOS APOTHACARY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-674-2018
Mailing Address - Street 1:1605 K66 STE B
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-4306
Mailing Address - Country:US
Mailing Address - Phone:620-783-1636
Mailing Address - Fax:620-783-1690
Practice Address - Street 1:1605 K66
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4306
Practice Address - Country:US
Practice Address - Phone:620-783-4441
Practice Address - Fax:620-783-1690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2-130703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200450780AMedicaid
2133997OtherPK
KS200867870AMedicaid