Provider Demographics
NPI:1548604523
Name:MULLEN PHARMACY PA INC
Entity Type:Organization
Organization Name:MULLEN PHARMACY PA INC
Other - Org Name:GRANT COUNTY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:620-356-1446
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-0570
Mailing Address - Country:US
Mailing Address - Phone:620-356-1446
Mailing Address - Fax:620-356-5381
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2130
Practice Address - Country:US
Practice Address - Phone:620-356-1446
Practice Address - Fax:620-356-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
KS2104473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140171OtherPK
KS201072420AMedicaid
KS201072420AMedicaid