Provider Demographics
NPI:1619966272
Name:PRESCRIPTION SHOP, INC
Entity Type:Organization
Organization Name:PRESCRIPTION SHOP, INC
Other - Org Name:PRESCRIPTION SHOP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFEVER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:913-515-0462
Mailing Address - Street 1:601 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-5025
Mailing Address - Country:US
Mailing Address - Phone:620-251-1620
Mailing Address - Fax:620-251-4730
Practice Address - Street 1:601 W 11TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-5025
Practice Address - Country:US
Practice Address - Phone:620-251-1620
Practice Address - Fax:620-251-4730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2091313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100434720BMedicaid
KS100434720AMedicaid
2030507OtherPK
KS100434720AMedicaid