Provider Demographics
NPI:1689911810
Name:THREE AMIGOS APOTHECARY LLC
Entity Type:Organization
Organization Name:THREE AMIGOS APOTHECARY LLC
Other - Org Name:CHERRYVALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-336-2144
Mailing Address - Street 1:203 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHERRYVALE
Mailing Address - State:KS
Mailing Address - Zip Code:67335-1332
Mailing Address - Country:US
Mailing Address - Phone:620-336-2144
Mailing Address - Fax:620-336-3285
Practice Address - Street 1:203 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHERRYVALE
Practice Address - State:KS
Practice Address - Zip Code:67335-1332
Practice Address - Country:US
Practice Address - Phone:620-336-2144
Practice Address - Fax:620-336-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-104073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy