Provider Demographics
NPI:1912949793
Name:PATEFIELD ENTERPRISES INC
Entity Type:Organization
Organization Name:PATEFIELD ENTERPRISES INC
Other - Org Name:MAIN ST APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-256-3511
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:NE
Mailing Address - Zip Code:68745-0515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:NE
Practice Address - Zip Code:68745-1989
Practice Address - Country:US
Practice Address - Phone:402-256-3511
Practice Address - Fax:402-256-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NE26663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025317900Medicaid
2810845OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NE10025317900Medicaid