MEDICARE: FOUR STATES APOTHECARY 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

General Provider Information

NPI Number	:	1952876948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUR STATES APOTHECARY LLC

Provider Business Mailing Address
First Line	:	413 COMMERCIAL ST
Second Line	:
City	:	OSWEGO
State	:	KS
Zip	:	67356-2017
Country	:	US
Telephone Number	:	620-795-2233
Fax Number	:	620-795-4910

Provider Business Practice Location Address
First Line	:	102 S MAIN ST
Second Line	:
City	:	CARL JUNCTION
State	:	MO
Zip	:	64834-1000
Country	:	US
Telephone Number	:	417-649-7021
Fax Number	:	417-649-6269

Authorized Official
Title or Position	:	PHARMACY OWNDER
Name	:	DR. MARK STEVEN MAYBERRY JR.
Credential	:	PHARMD
Telephone Number	:	417-529-1815

Provider Enumeration Date	:	10/05/2018
Last Update Date	:	10/05/2018

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