1427199090 NPI number — HEALTH CARE PHARMACY OF PERRYVILLE, LLC

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 1427199090 NPI number — HEALTH CARE PHARMACY OF PERRYVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH CARE PHARMACY OF PERRYVILLE, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1427199090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
628 N. OLD ST. MARYS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRYVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-547-2517
Provider Business Mailing Address Fax Number:
573-547-7758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 OLD SAINT MARYS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRYVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63775-1837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-547-2517
Provider Business Practice Location Address Fax Number:
573-547-7758
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GROGG
Authorized Official First Name:
SAVANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
573-535-4911

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2017038581 , 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)





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