1578669701 NPI number — TIM MITCHELL MEDICAL, INC

Table of content: (NPI 1578669701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578669701 NPI number — TIM MITCHELL MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIM MITCHELL MEDICAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MITCHELL'S DRUG STORE ON THE BOULEVARD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578669701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
719 S NEOSHO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEOSHO
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64850-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-455-1883
Provider Business Mailing Address Fax Number:
417-455-2781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 S NEOSHO BLVD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
NEOSHO
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-451-9501
Provider Business Practice Location Address Fax Number:
417-451-9594
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
417-451-9501

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2003027740 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200642940A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200286710A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 602932303 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 622932309 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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