Healthcare Provider Details

I. General information

NPI: 1528375508
Provider Name (Legal Business Name): MISSOURI PHARMACIST CARE NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2010
Last Update Date: 09/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E CAPITOL AVE
JEFFERSON CITY MO
65101-3001
US

IV. Provider business mailing address

211 E CAPITOL AVE
JEFFERSON CITY MO
65101-3001
US

V. Phone/Fax

Practice location:
  • Phone: 573-636-7522
  • Fax: 573-636-7485
Mailing address:
  • Phone: 573-636-7522
  • Fax: 573-636-7485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: RON FITZWATER
Title or Position: MANAGER
Credential: CAE
Phone: 573-636-7522