MEDICARE: MISSOURI MED 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	332BN1400X	Nursing Facility Supplies (DME)	2018005320	MO
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care 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
2	2176054	OTHER		PK

General Provider Information

NPI Number	:	1518465533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI MED LLC

Provider Business Mailing Address
First Line	:	2215 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4403
Country	:	US
Telephone Number	:	573-335-3044
Fax Number	:	573-335-6724

Provider Business Practice Location Address
First Line	:	2215 BROADWAY
Second Line	:	SUITE B
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-4403
Country	:	US
Telephone Number	:	573-803-5500
Fax Number	:	573-803-5501

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JACKIE MCHUGH
Credential	:
Telephone Number	:	573-335-3044

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	03/03/2026

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Directions to “MISSOURI MED LLC ” Practice Location

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