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General NPI Number Information
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NPI Number | 1972980829
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Entity Type | Organization
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Legal Business Name | COUNTRY MART PHARMACY
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Dates
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Enumeration Date | 04/29/2015
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 235 GERARD ST
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City | STE GENEVIEVE
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State | MO
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Zip | 63670-1713
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Country | US
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Telephone | 312-547-9845
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Fax |
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Provider Business Mailing Address
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Address Line | 235 GERARD ST
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City | STE GENEVIEVE
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State | MO
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Zip | 63670-1713
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Country | US
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Telephone | 312-547-9845
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Fax |
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Authorized Official
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Title or Position | PIC
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Name | ERIKA HAHN
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Credential | PHARMD
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Telephone | 573-358-0099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2011030562
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License Number State | MO
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