Provider Demographics
NPI:1982121109
Name:NEVADA STATE PHARMACY - LAS VEGAS LLC
Entity Type:Organization
Organization Name:NEVADA STATE PHARMACY - LAS VEGAS LLC
Other - Org Name:NEVADA STATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-916-1600
Mailing Address - Street 1:3022 W POST RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3836
Mailing Address - Country:US
Mailing Address - Phone:702-916-1600
Mailing Address - Fax:702-916-1900
Practice Address - Street 1:3022 W POST RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3836
Practice Address - Country:US
Practice Address - Phone:702-916-1600
Practice Address - Fax:702-916-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
NVPH038153336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2171424OtherPK