Provider Demographics
NPI:1447265863
Name:MDSLC INC
Entity type:Organization
Organization Name:MDSLC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-282-1114
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:NE
Mailing Address - Zip Code:69343-1524
Mailing Address - Country:US
Mailing Address - Phone:308-282-1114
Mailing Address - Fax:308-282-2250
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:NE
Practice Address - Zip Code:69343-1524
Practice Address - Country:US
Practice Address - Phone:308-282-1114
Practice Address - Fax:308-282-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NE30213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145896OtherPK
NE10026444200/8534700Medicaid