Healthcare Provider Details

I. General information

NPI: 1497790968
Provider Name (Legal Business Name): PRESCRIPTION DRUG STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 WARD AVE
CARUTHERSVILLE MO
63830
US

IV. Provider business mailing address

410 WARD AVE
CARUTHERSVILLE MO
63830
US

V. Phone/Fax

Practice location:
  • Phone: 573-333-4890
  • Fax: 573-333-0306
Mailing address:
  • Phone: 573-333-4890
  • Fax: 573-333-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number000915
License Number StateMO

VIII. Authorized Official

Name: MR. SHANE ALAN DUDLEY
Title or Position: OWNER / PHARMACIST
Credential: RPH
Phone: 573-333-4890