Basic Information
| Provider Information | |||||||||
| NPI: | 1225124357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STORMONT VAIL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STORMONT VAIL RETAIL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SW 10TH AVE | ||||||||
| Address2: | CORPORATE FINANCE | ||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666041301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853546000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2252 SW 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666043929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852358796 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGLAND | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7853546167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 2-08850 | KS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100443290A | 05 | KS | MEDICAID | 1707441 | 01 | NCPDP OR NABP NUMBER | OTHER |