Healthcare Provider Details

I. General information

NPI: 1497254809
Provider Name (Legal Business Name): LA PLATA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N MACON ST
BEVIER MO
63532-1058
US

IV. Provider business mailing address

221 N. MACON STREET
BEVIER MO
63532
US

V. Phone/Fax

Practice location:
  • Phone: 660-346-0449
  • Fax: 660-773-5529
Mailing address:
  • Phone: 660-346-0449
  • Fax: 660-773-5529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2018004056
License Number StateMO

VIII. Authorized Official

Name: JAMIE PROKUP
Title or Position: OWNER
Credential:
Phone: 660-346-0449