Healthcare Provider Details

I. General information

NPI: 1013089804
Provider Name (Legal Business Name): QUEEN CITY PHARMACIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 N BOONVILLE AVE
SPRINGFIELD MO
65802-1806
US

IV. Provider business mailing address

1474 N BOONVILLE AVE
SPRINGFIELD MO
65802-1806
US

V. Phone/Fax

Practice location:
  • Phone: 417-869-1866
  • Fax: 417-869-6601
Mailing address:
  • Phone: 417-869-1866
  • Fax: 417-869-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number006537
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2017031169
License Number StateMO

VIII. Authorized Official

Name: REBEKAH ANN ROSE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 417-881-8841