Provider Demographics
NPI:1780754218
Name:GRAVES DRUG STORE #11
Entity type:Organization
Organization Name:GRAVES DRUG STORE #11
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-442-2300
Mailing Address - Street 1:212 SOUTH SUMMIT
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005
Mailing Address - Country:US
Mailing Address - Phone:620-442-2300
Mailing Address - Fax:620-442-9498
Practice Address - Street 1:212 SOUTH SUMMIT
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005
Practice Address - Country:US
Practice Address - Phone:620-442-2300
Practice Address - Fax:620-442-9498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0493790001Medicare ID - Type Unspecified