Provider Demographics
NPI:1003963760
Name:VALENTINE CLINIC PHARMACY
Entity Type:Organization
Organization Name:VALENTINE CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:402-376-3531
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-0176
Mailing Address - Country:US
Mailing Address - Phone:402-376-3531
Mailing Address - Fax:402-376-3560
Practice Address - Street 1:272 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1818
Practice Address - Country:US
Practice Address - Phone:402-376-3531
Practice Address - Fax:402-376-3560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8531160Medicaid
SD8531160Medicaid
NE=========00Medicaid