Provider Demographics
NPI:1497869465
Name:LOUDERBACK DRUG OF MADISON INC
Entity Type:Organization
Organization Name:LOUDERBACK DRUG OF MADISON INC
Other - Org Name:LOUDERBACK DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:402-454-2525
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:PO BOX 389
Mailing Address - City:MADISON
Mailing Address - State:NE
Mailing Address - Zip Code:68748-6485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NE
Practice Address - Zip Code:68748-6485
Practice Address - Country:US
Practice Address - Phone:402-454-2525
Practice Address - Fax:402-454-2945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X, 3336S0011X
NE26713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2055498OtherPK
NE4708556900Medicaid