Healthcare Provider Details

I. General information

NPI: 1003849316
Provider Name (Legal Business Name): MEDKIN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PROGRESS PKWY
SULLIVAN MO
63080-2359
US

IV. Provider business mailing address

105 PROGRESS PKWY MEDICINE CABINET PHARMACY
SULLIVAN MO
63080-2359
US

V. Phone/Fax

Practice location:
  • Phone: 573-860-3600
  • Fax: 573-860-2636
Mailing address:
  • Phone: 573-860-3600
  • Fax: 573-860-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5100
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2003001706
License Number StateMO

VIII. Authorized Official

Name: MR. JOHN WAYNE HEWKIN
Title or Position: MEMBER/OWNER/PHARMACIST
Credential: RPH.
Phone: 573-308-5033