=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962973743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREEZE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2018
-----------------------------------------------------
Last Update Date | 12/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 N GRAND ST STE 1
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65661-8198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-637-2909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 158
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65661-0158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALLISON FREEZE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-388-5826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------