Provider Demographics
NPI:1083029359
Name:MONTEZUMA DRUG LLC
Entity Type:Organization
Organization Name:MONTEZUMA DRUG LLC
Other - Org Name:MONTEZUMA DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:HELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-846-2202
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:KS
Mailing Address - Zip Code:67867-0128
Mailing Address - Country:US
Mailing Address - Phone:620-846-2202
Mailing Address - Fax:620-846-7130
Practice Address - Street 1:300 N AZTEC ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:KS
Practice Address - Zip Code:67867-8874
Practice Address - Country:US
Practice Address - Phone:620-846-2202
Practice Address - Fax:620-846-7130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KS2-130423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147191OtherPK
KS201107230AMedicaid
2147191OtherPK
5274140001Medicare UPIN