Provider Demographics
NPI:1750447470
Name:SUMNER PHARMACY, INC.
Entity Type:Organization
Organization Name:SUMNER PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:563-578-5142
Mailing Address - Street 1:100 E 1ST ST
Mailing Address - Street 2:PO BOX 205
Mailing Address - City:SUMNER
Mailing Address - State:IA
Mailing Address - Zip Code:50674-1430
Mailing Address - Country:US
Mailing Address - Phone:563-578-5142
Mailing Address - Fax:563-578-5190
Practice Address - Street 1:100 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IA
Practice Address - Zip Code:50674-1430
Practice Address - Country:US
Practice Address - Phone:563-578-5142
Practice Address - Fax:563-578-5190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA43333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0125351Medicaid
IA0307390001Medicare ID - Type Unspecified