Healthcare Provider Details

I. General information

NPI: 1689700379
Provider Name (Legal Business Name): MAIN STREET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E MAIN ST
EAST PRAIRIE MO
63845-1136
US

IV. Provider business mailing address

117 E MAIN ST
EAST PRAIRIE MO
63845-1136
US

V. Phone/Fax

Practice location:
  • Phone: 573-649-9229
  • Fax: 573-649-9230
Mailing address:
  • Phone: 573-649-9229
  • Fax: 573-649-9230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2013000674
License Number StateMO

VIII. Authorized Official

Name: TERA JOHNSON
Title or Position: MANAGER
Credential:
Phone: 573-649-9229