Provider Demographics
NPI:1265443774
Name:PHILLIP A QUALEY
Entity Type:Organization
Organization Name:PHILLIP A QUALEY
Other - Org Name:ADAMS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:QUALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-582-3380
Mailing Address - Street 1:PO BOX 324
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:MN
Mailing Address - Zip Code:55909-0324
Mailing Address - Country:US
Mailing Address - Phone:507-582-3380
Mailing Address - Fax:507-582-1024
Practice Address - Street 1:11 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:MN
Practice Address - Zip Code:55909-9688
Practice Address - Country:US
Practice Address - Phone:507-582-3380
Practice Address - Fax:507-582-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2599783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN659057800Medicaid
2414403OtherNCPDP PROVIDER IDENTIFICATION NUMBER