Basic Information
Provider Information | |||||||||
NPI: | 1760576193 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KELLOGG DRUGS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNNYSIDE DRUG | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5908 BRECKENRIDGE PARKWAY | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 33610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133042221 | ||||||||
FaxNumber: | 8882398423 | ||||||||
Practice Location | |||||||||
Address1: | 131 WEST CAMERON AVE | ||||||||
Address2: |   | ||||||||
City: | KELLOGG | ||||||||
State: | ID | ||||||||
PostalCode: | 83837 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087846221 | ||||||||
FaxNumber: | 2085567311 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 09/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHACKELFORD | ||||||||
AuthorizedOfficialFirstName: | TONYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACY OWNER | ||||||||
AuthorizedOfficialTelephone: | 8133042221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OSBURN DRUG CO. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.