Healthcare Provider Details

I. General information

NPI: 1255362737
Provider Name (Legal Business Name): MILLER REXALL DRUG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 VINE ST
MACON MO
63552-1654
US

IV. Provider business mailing address

PO BOX 486 115 VINE ST
MACON MO
63552-0486
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-2167
  • Fax: 660-385-6245
Mailing address:
  • Phone: 660-385-2167
  • Fax: 660-385-6245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE MIGNON KLINGSMITH
Title or Position: PIC
Credential:
Phone: 660-385-2167