Provider Demographics
NPI:1508324021
Name:MINNEOLA PHARMACY II LLC
Entity Type:Organization
Organization Name:MINNEOLA PHARMACY II LLC
Other - Org Name:MINNEOLA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRANADOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MPH
Authorized Official - Phone:620-885-4544
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:KS
Mailing Address - Zip Code:67865-0460
Mailing Address - Country:US
Mailing Address - Phone:620-885-4544
Mailing Address - Fax:620-885-4723
Practice Address - Street 1:131 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:KS
Practice Address - Zip Code:67865-0460
Practice Address - Country:US
Practice Address - Phone:620-885-4544
Practice Address - Fax:620-885-4723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-04
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201318470AMedicaid
KS1447353503OtherNPI