Provider Demographics
NPI:1194828194
Name:PHARMACON DRUG
Entity Type:Organization
Organization Name:PHARMACON DRUG
Other - Org Name:DERBY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-788-5533
Mailing Address - Street 1:1101 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3735
Mailing Address - Country:US
Mailing Address - Phone:316-788-6669
Mailing Address - Fax:316-788-3570
Practice Address - Street 1:1101 N ROCK RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3735
Practice Address - Country:US
Practice Address - Phone:316-788-6669
Practice Address - Fax:316-788-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS79343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100437990AMedicaid
KS0445840002Medicare NSC
KS100437990AMedicaid