Provider Demographics
NPI:1083614697
Name:PALACE DRUG STORE INC
Entity Type:Organization
Organization Name:PALACE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:785-460-7507
Mailing Address - Street 1:460 N FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-2326
Mailing Address - Country:US
Mailing Address - Phone:785-460-7507
Mailing Address - Fax:785-460-2522
Practice Address - Street 1:460 N FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:KS
Practice Address - Zip Code:67701-2326
Practice Address - Country:US
Practice Address - Phone:785-460-7507
Practice Address - Fax:785-460-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS206543333600000X, 333600000X
KS2-065433336C0003X, 3336L0003X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100437940BMedicaid
KS100437940BMedicaid