Healthcare Provider Details

I. General information

NPI: 1326187212
Provider Name (Legal Business Name): ST OF MO FULTON ST HOSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 5TH ST
FULTON MO
65251-1753
US

IV. Provider business mailing address

600 E 5TH ST
FULTON MO
65251-1753
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-3062
  • Fax: 573-592-3070
Mailing address:
  • Phone: 573-592-3062
  • Fax: 573-592-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number001897
License Number StateMO

VIII. Authorized Official

Name: MOLLY JANE BOECKMANN
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 573-751-4055