Provider Demographics
NPI:1740291558
Name:GOTHENBURG DISCOUNT PHARMACY INC.
Entity type:Organization
Organization Name:GOTHENBURG DISCOUNT PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:KREIS
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:308-537-7155
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-0159
Mailing Address - Country:US
Mailing Address - Phone:308-537-7155
Mailing Address - Fax:308-537-7366
Practice Address - Street 1:902 AVENUE D STE 102
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1955
Practice Address - Country:US
Practice Address - Phone:308-537-7155
Practice Address - Fax:308-537-7366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3060314000000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
2809688OtherNCPDP
NE47059868200Medicaid
NE0141970001Medicare UPIN