1679648851 NPI number — SUMMERS PHARMACY NO 11 INC

Table of content: (NPI 1679648851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679648851 NPI number — SUMMERS PHARMACY NO 11 INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERS PHARMACY NO 11 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:
SUMMERS PHARMACY - BOONVILLE
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:
1679648851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 PAWNEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64735-2757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-383-1910
Provider Business Mailing Address Fax Number:
660-885-5888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65233-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-882-5208
Provider Business Practice Location Address Fax Number:
660-882-8125
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUMMERS
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
660-885-3034

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 002291 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 600284400 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2048680 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com