Healthcare Provider Details

I. General information

NPI: 1083695902
Provider Name (Legal Business Name): TOWN & COUNTRY SUPER MARKET INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E 5TH ST
DIXON MO
65459-6201
US

IV. Provider business mailing address

PO BOX 748
SALEM MO
65560-0748
US

V. Phone/Fax

Practice location:
  • Phone: 573-759-3073
  • Fax: 573-759-3560
Mailing address:
  • Phone: 573-729-4091
  • Fax: 573-729-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2005015586
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2005015586
License Number StateMO

VIII. Authorized Official

Name: MRS. JANET GOTT
Title or Position: PHARMACY SUPERVISOR
Credential: RPH
Phone: 573-729-4091