=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093731408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACK'S GROCERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 02/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1047 S MAGUIRE ST
-----------------------------------------------------
City | WARRENSBURG
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64093-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-747-7449
-----------------------------------------------------
Fax | 660-747-5037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1117
-----------------------------------------------------
City | WARRENSBURG
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64093-7117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-747-7449
-----------------------------------------------------
Fax | 660-747-5037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | MR. LUKE A HAGLE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 660-747-7449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2004007107
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------