1083035760 NPI number — L&J PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083035760 NPI number — L&J PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L&J PHARMACY 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:
MOM AND POP DRUG #1 SPECIALTY
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:
1083035760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65742-0260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-753-7774
Provider Business Mailing Address Fax Number:
417-753-7786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 S MAIN ST STE N-2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65742-9361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-753-7774
Provider Business Practice Location Address Fax Number:
417-753-7786
Provider Enumeration Date:
12/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COKER
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-459-1436

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 2013045671 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2143040 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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