Healthcare Provider Details

I. General information

NPI: 1467432112
Provider Name (Legal Business Name): MNM PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 MAIN ST
CABOOL MO
65689-8104
US

IV. Provider business mailing address

518 MAIN ST
CABOOL MO
65689-8104
US

V. Phone/Fax

Practice location:
  • Phone: 417-962-3133
  • Fax: 417-962-5393
Mailing address:
  • Phone: 417-962-3133
  • Fax: 417-962-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2016004609
License Number StateMO

VIII. Authorized Official

Name: MIKA LINDSEY
Title or Position: MANAGING MEMBER
Credential:
Phone: 417-962-3133