Provider Demographics
NPI:1013460922
Name:HODGEMAN COUNTY PHARMACY LLC
Entity Type:Organization
Organization Name:HODGEMAN COUNTY PHARMACY LLC
Other - Org Name:HODGEMAN COUNTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-855-2055
Mailing Address - Street 1:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:CIMARRON
Mailing Address - State:KS
Mailing Address - Zip Code:67835-0782
Mailing Address - Country:US
Mailing Address - Phone:620-855-2055
Mailing Address - Fax:620-855-2052
Practice Address - Street 1:519 MAIN STREET
Practice Address - Street 2:
Practice Address - City:JETMORE
Practice Address - State:KS
Practice Address - Zip Code:67854
Practice Address - Country:US
Practice Address - Phone:620-357-8305
Practice Address - Fax:620-855-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-100543333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162209OtherPK
KS201138190AMedicaid