1568694297 NPI number — SHELBINA PHARMACY L L C

Table of content: (NPI 1568694297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568694297 NPI number — SHELBINA PHARMACY L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBINA PHARMACY L L C
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:
1568694297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 N CENTER ST
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
SHELBINA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63468-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-588-2143
Provider Business Mailing Address Fax Number:
573-588-7545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N CENTER ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
SHELBINA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63468-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-588-2143
Provider Business Practice Location Address Fax Number:
573-588-7545
Provider Enumeration Date:
08/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EARLEY
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
573-588-2143

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2015016416 , 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: 2121570 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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