Provider Demographics
NPI:1457435711
Name:GRETNA DRUG
Entity Type:Organization
Organization Name:GRETNA DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WENDLANDT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:402-332-5990
Mailing Address - Street 1:820 VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7914
Mailing Address - Country:US
Mailing Address - Phone:402-332-5990
Mailing Address - Fax:402-332-0266
Practice Address - Street 1:820 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-7914
Practice Address - Country:US
Practice Address - Phone:402-332-5990
Practice Address - Fax:402-332-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2604333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2816710OtherNABP #
NE10025112900Medicaid
NE10025112900Medicaid
NE099613Medicare PIN
NE5124630001Medicare NSC