Provider Demographics
NPI:1720154826
Name:THREE AMIGOS APOTHECARY LLC
Entity Type:Organization
Organization Name:THREE AMIGOS APOTHECARY LLC
Other - Org Name:CHERRYVALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-674-2018
Mailing Address - Street 1:116 N MAPLE ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHERRYVALE
Mailing Address - State:KS
Mailing Address - Zip Code:67335-1729
Mailing Address - Country:US
Mailing Address - Phone:620-336-2144
Mailing Address - Fax:620-336-3285
Practice Address - Street 1:116 N MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:CHERRYVALE
Practice Address - State:KS
Practice Address - Zip Code:67335-1729
Practice Address - Country:US
Practice Address - Phone:620-336-2144
Practice Address - Fax:620-336-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KS2-104073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140553OtherPK
KS200867870BMedicaid