Provider Demographics
NPI:1720146970
Name:SHAWNEE MISSION MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SHAWNEE MISSION MEDICAL CENTER INC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:913-789-3976
Mailing Address - Street 1:9100 W. 74TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-789-3976
Mailing Address - Fax:913-789-6730
Practice Address - Street 1:9100 W. 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-789-3976
Practice Address - Fax:913-789-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KS2097643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027055OtherPK
KS100007000BMedicaid