Provider Demographics
NPI:1720120025
Name:SKAGWAY DISC DEPT. STORES, INC.
Entity Type:Organization
Organization Name:SKAGWAY DISC DEPT. STORES, INC.
Other - Org Name:SKAGWAY PHARMACY # 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-384-8222
Mailing Address - Street 1:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-1647
Mailing Address - Country:US
Mailing Address - Phone:308-384-8228
Mailing Address - Fax:308-384-6835
Practice Address - Street 1:620 STATE ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-3552
Practice Address - Country:US
Practice Address - Phone:308-384-8228
Practice Address - Fax:308-384-6835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2800779OtherNCPDP OR NABP NO.
NE=========02Medicaid
NE0367450002Medicare ID - Type Unspecified