Healthcare Provider Details

I. General information

NPI: 1144798679
Provider Name (Legal Business Name): MEDLEY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 E 10TH ST STE B
ROLLA MO
65401-3591
US

IV. Provider business mailing address

PO BOX 528
CUBA MO
65453-0528
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-9616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LOCAL HEALTH MISSOURI INC
Title or Position: OWNER
Credential:
Phone: 573-885-0885