Healthcare Provider Details

I. General information

NPI: 1144266651
Provider Name (Legal Business Name): FREDERICKTOWN MEDICATE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E MAIN ST
FREDERICKTOWN MO
63645-1123
US

IV. Provider business mailing address

111 E MAIN ST
FREDERICKTOWN MO
63645-1123
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-5508
  • Fax: 573-783-3289
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number002797
License Number StateMO

VIII. Authorized Official

Name: PATRICK OBRIEN
Title or Position: OWNER
Credential: RPH
Phone: 573-783-5508