Basic Information
| Provider Information | |||||||||
| NPI: | 1093755811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DILLON COMPANIES LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | DILLON PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842772 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022842772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137621019 | ||||||||
| FaxNumber: | 6206691894 | ||||||||
| Practice Location | |||||||||
| Address1: | 3211 S SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165224545 | ||||||||
| FaxNumber: | 3165299013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARMAN | ||||||||
| AuthorizedOfficialFirstName: | JESSIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF PHARMACY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 5137621019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 9638 | KS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2073306 | 05 | WA | MEDICAID | 2032319 | 01 | PK | OTHER | 100431640A | 05 | KS | MEDICAID |