Provider Demographics
NPI:1003914615
Name:HOMETOWN DEVELOPMENT
Entity Type:Organization
Organization Name:HOMETOWN DEVELOPMENT
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-882-4863
Mailing Address - Street 1:1324 BROADWAY; PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:NE
Mailing Address - Zip Code:69033-0597
Mailing Address - Country:US
Mailing Address - Phone:308-882-4863
Mailing Address - Fax:308-882-4510
Practice Address - Street 1:1324 BROADWAY
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:NE
Practice Address - Zip Code:69033-0597
Practice Address - Country:US
Practice Address - Phone:308-882-4863
Practice Address - Fax:308-882-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025337400Medicaid
NE5615110001Medicare ID - Type Unspecified