MEDICARE: MT OREAD PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	08834	KS
2	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083834998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT OREAD PHARMACY LLC

Provider Business Mailing Address
First Line	:	3510 CLINTON PARKWAY PLACE
Second Line	:	SUITE 220
City	:	LAWRENCE
State	:	KS
Zip	:	66047-2195
Country	:	US
Telephone Number	:	785-843-0111
Fax Number	:	785-843-3818

Provider Business Practice Location Address
First Line	:	3510 CLINTON PARKWAY PLACE
Second Line	:	SUITE 220
City	:	LAWRENCE
State	:	KS
Zip	:	66047-2195
Country	:	US
Telephone Number	:	785-843-0111
Fax Number	:	785-843-3818

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MR. ERICK W AXCELL
Credential	:	PHARMD
Telephone Number	:	785-843-0111

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	10/09/2020

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