Provider Demographics
NPI:1518476399
Name:STAFFORD COUNTY DRUG
Entity Type:Organization
Organization Name:STAFFORD COUNTY DRUG
Other - Org Name:STAFFORD COUNTY DRUG
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-886-5161
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:KS
Mailing Address - Zip Code:67576-0247
Mailing Address - Country:US
Mailing Address - Phone:620-377-5633
Mailing Address - Fax:
Practice Address - Street 1:329A N US HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:KS
Practice Address - Zip Code:67576-8309
Practice Address - Country:US
Practice Address - Phone:620-377-5633
Practice Address - Fax:620-377-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
KS2-1039863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2171587OtherPK