Provider Demographics
NPI:1851434872
Name:MAHANNA PHARMACY INC
Entity Type:Organization
Organization Name:MAHANNA PHARMACY INC
Other - Org Name:MAHANNA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:785-675-3461
Mailing Address - Street 1:PO BOX 288
Mailing Address - Street 2:
Mailing Address - City:HOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:67740-0288
Mailing Address - Country:US
Mailing Address - Phone:785-675-3461
Mailing Address - Fax:785-675-3112
Practice Address - Street 1:833 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOXIE
Practice Address - State:KS
Practice Address - Zip Code:67740-9735
Practice Address - Country:US
Practice Address - Phone:785-675-3112
Practice Address - Fax:785-675-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2-090993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100434540AMedicaid
2031038OtherPK
0534130001Medicare NSC