Healthcare Provider Details

I. General information

NPI: 1205584091
Provider Name (Legal Business Name): FOOD MERCHANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 W KEARNEY ST
SPRINGFIELD MO
65803-2037
US

IV. Provider business mailing address

PO BOX 397
NIXA MO
65714-0397
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-1547
  • Fax: 417-862-2571
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERICA LYNN MAHN
Title or Position: DIRECTOR OF COMMUNITY PHARMACY
Credential: PHARMD
Phone: 417-865-1547