Healthcare Provider Details

I. General information

NPI: 1518263110
Provider Name (Legal Business Name): FAMILY PHARMACY OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 STATE HIGHWAY 14 W STE F
CLEVER MO
65631-6799
US

IV. Provider business mailing address

PO BOX 68
CLEVER MO
65631-0068
US

V. Phone/Fax

Practice location:
  • Phone: 417-583-2595
  • Fax: 417-583-2097
Mailing address:
  • Phone: 417-583-2595
  • Fax: 417-583-2097

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 Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2011001788
License Number StateMO

VIII. Authorized Official

Name: CARRIE TENNIS
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 417-581-4335