Provider Demographics
NPI:1639277833
Name:SCOTT CITY PHARMACY
Entity Type:Organization
Organization Name:SCOTT CITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BRUNSWIG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:620-872-2146
Mailing Address - Street 1:102 ALBERT AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67871
Mailing Address - Country:US
Mailing Address - Phone:620-872-2146
Mailing Address - Fax:620-872-7099
Practice Address - Street 1:102 ALBERT AVENUE
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:KS
Practice Address - Zip Code:67871
Practice Address - Country:US
Practice Address - Phone:620-872-2146
Practice Address - Fax:620-872-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100432180AMedicaid
KSBS8303858OtherDEA NUMBER
KS100432180AMedicaid