MEDICARE: MEDKIN PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	2003001706	MO
2	333600000X	Pharmacy	5100	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5100	OTHER	MO	MO BOARD OF PHARMA

General Provider Information

NPI Number	:	1003849316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDKIN PHARMACY LLC

Provider Business Mailing Address
First Line	:	105 PROGRESS PKWY
Second Line	:	MEDICINE CABINET PHARMACY
City	:	SULLIVAN
State	:	MO
Zip	:	63080-2359
Country	:	US
Telephone Number	:	573-860-3600
Fax Number	:	573-860-2636

Provider Business Practice Location Address
First Line	:	105 PROGRESS PKWY
Second Line	:
City	:	SULLIVAN
State	:	MO
Zip	:	63080-2359
Country	:	US
Telephone Number	:	573-860-3600
Fax Number	:	573-860-2636

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	11/16/2009

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Directions to “MEDKIN PHARMACY LLC ” Practice Location

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