Healthcare Provider Details

I. General information

NPI: 1033217062
Provider Name (Legal Business Name): FAMILY PHARMACY OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 W BROADWAY ST
BOLIVAR MO
65613-1815
US

IV. Provider business mailing address

1326 W BROADWAY ST
BOLIVAR MO
65613-1815
US

V. Phone/Fax

Practice location:
  • Phone: 417-326-8747
  • Fax: 417-326-8748
Mailing address:
  • Phone: 417-326-8747
  • Fax: 417-326-8748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2006014908
License Number StateMO

VIII. Authorized Official

Name: LYNN MORRIS
Title or Position: PRESIDENT
Credential: RPH MS
Phone: 417-581-4335