Provider Demographics
NPI:1285044032
Name:BLPS LLC
Entity Type:Organization
Organization Name:BLPS LLC
Other - Org Name:MEDICINE MAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:STAIGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:402-652-3217
Mailing Address - Street 1:748 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68649-5003
Mailing Address - Country:US
Mailing Address - Phone:402-652-3217
Mailing Address - Fax:402-652-8219
Practice Address - Street 1:748 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:NE
Practice Address - Zip Code:68649-5003
Practice Address - Country:US
Practice Address - Phone:402-652-3217
Practice Address - Fax:402-652-8219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
NE30343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146052OtherPK
NE3034OtherSTATE PHARMACY LICENSE NUMBER
NE10026406100Medicaid