Healthcare Provider Details

I. General information

NPI: 1003327537
Provider Name (Legal Business Name): MISSOURI LTC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6129 WEST US HIGHWAY 60
BROOKLINE MO
65619
US

IV. Provider business mailing address

6129 W US HIGHWAY 60
BROOKLINE MO
65619-9441
US

V. Phone/Fax

Practice location:
  • Phone: 417-708-5050
  • Fax: 417-708-5055
Mailing address:
  • Phone: 417-780-5050
  • Fax: 417-780-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number2017040311
License Number StateMO

VIII. Authorized Official

Name: JANICE S CERIOTTI
Title or Position: CHIEF OPERATING OFFICER
Credential: RPH
Phone: 314-690-4500