Provider Demographics
NPI:1902107345
Name:SOUTH LOUP COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:SOUTH LOUP COMMUNITY PHARMACY
Other - Org Name:SOUTH LOUP COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:D
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-836-2228
Mailing Address - Street 1:200 E PACIFIC ST
Mailing Address - Street 2:P.O. BOX 220
Mailing Address - City:CALLAWAY
Mailing Address - State:NE
Mailing Address - Zip Code:68825-2500
Mailing Address - Country:US
Mailing Address - Phone:308-836-2219
Mailing Address - Fax:308-836-2625
Practice Address - Street 1:200 E PACIFIC ST
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:NE
Practice Address - Zip Code:68825-2500
Practice Address - Country:US
Practice Address - Phone:308-836-2219
Practice Address - Fax:308-836-2625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127586OtherPK