Provider Demographics
NPI:1659361640
Name:KWASNIEWSKI ENTERPRISES INC
Entity Type:Organization
Organization Name:KWASNIEWSKI ENTERPRISES INC
Other - Org Name:CORNWELL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KWASNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-345-3351
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57274-0490
Mailing Address - Country:US
Mailing Address - Phone:605-345-3351
Mailing Address - Fax:605-345-3352
Practice Address - Street 1:701 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:SD
Practice Address - Zip Code:57274-1305
Practice Address - Country:US
Practice Address - Phone:605-345-3351
Practice Address - Fax:605-345-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
SD10018213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8500742Medicaid
2093886OtherPK
4148750001Medicare NSC