Healthcare Provider Details

I. General information

NPI: 1154621803
Provider Name (Legal Business Name): MARSHFIELD CLINIC PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 POMME DE TERRE
MARSHFIELD MO
65706-2386
US

IV. Provider business mailing address

483 POMME DE TERRE
MARSHFIELD MO
65706-2386
US

V. Phone/Fax

Practice location:
  • Phone: 417-468-4442
  • Fax: 417-468-4462
Mailing address:
  • Phone: 417-468-4442
  • Fax: 417-468-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2004036065
License Number StateMO

VIII. Authorized Official

Name: MR. MICHAEL ANTHONY VINEHOUT
Title or Position: OWNER/PHARMACIST-IN-CHARGE
Credential: RPH
Phone: 417-468-4442