Provider Demographics
NPI:1962658633
Name:INDEPENDENCE PHARMACY
Entity Type:Organization
Organization Name:INDEPENDENCE PHARMACY
Other - Org Name:INDEPENDENCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-331-3784
Mailing Address - Street 1:205 N PENN AVE
Mailing Address - Street 2:PO BOX 71
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-3323
Mailing Address - Country:US
Mailing Address - Phone:620-331-3784
Mailing Address - Fax:620-331-1701
Practice Address - Street 1:205 N PENN AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3323
Practice Address - Country:US
Practice Address - Phone:620-331-3784
Practice Address - Fax:620-331-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KS2-101993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200568190AMedicaid
KS200568190BMedicaid
2116608OtherPK
6296720001Medicare NSC