Provider Demographics
NPI:1205187739
Name:CASEYS PRESCRIPTION PAD INC
Entity Type:Organization
Organization Name:CASEYS PRESCRIPTION PAD INC
Other - Org Name:CASEY'S PRESCRIPTION PAD, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DERCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-926-9044
Mailing Address - Street 1:5844 SOUTHWESTERN BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-3684
Mailing Address - Country:US
Mailing Address - Phone:716-926-9044
Mailing Address - Fax:716-926-9028
Practice Address - Street 1:5844 SOUTHWESTERN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-926-9044
Practice Address - Fax:716-926-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0314693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137096OtherPK
NY03737657Medicaid
NY03737657Medicaid