Provider Demographics
NPI:1558364141
Name:HODGINS DRUG STORE, INC.
Entity Type:Organization
Organization Name:HODGINS DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-882-5536
Mailing Address - Street 1:307 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2913
Mailing Address - Country:US
Mailing Address - Phone:208-882-5536
Mailing Address - Fax:208-882-4741
Practice Address - Street 1:307 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2913
Practice Address - Country:US
Practice Address - Phone:208-882-5536
Practice Address - Fax:208-882-4741
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HODGINS DRUG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-27
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID065CP332B00000X, 333600000X, 335E00000X
IDH244332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332S00000XSuppliersHearing Aid Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID70011OtherBLUE CROSS OF IDAHO RX
WA6013833Medicaid
ID000010014112OtherREGENCE BLUE SHIELD DME
ID002302500Medicaid
ID805459300Medicaid
WA6013833Medicaid