1326490376 NPI number — GUARDIAN PHARMACY OF MISSOURI LLC

Table of content: (NPI 1326490376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326490376 NPI number — GUARDIAN PHARMACY OF MISSOURI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF MISSOURI 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:
1326490376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2107 E ROCKHURST ST STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65802-6502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0094
Provider Business Mailing Address Fax Number:
404-810-0089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2107 E ROCKHURST ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65802-6502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-864-5873
Provider Business Practice Location Address Fax Number:
417-864-5874
Provider Enumeration Date:
07/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COUNTS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-864-5873

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  2016023396 , 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: 1326490376 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2166287 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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