Provider Demographics
NPI:1184215113
Name:STAFFORD COUNTY DRUG
Entity Type:Organization
Organization Name:STAFFORD COUNTY DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-377-5633
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:KS
Mailing Address - Zip Code:67576-0247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:329A N US HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:KS
Practice Address - Zip Code:67576-8309
Practice Address - Country:US
Practice Address - Phone:620-377-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201170370AMedicaid