Provider Demographics
NPI:1003327537
Name:MISSOURI LTC PHARMACY LLC
Entity Type:Organization
Organization Name:MISSOURI LTC PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERAITONS
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CERIOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:314-690-4500
Mailing Address - Street 1:6129 W US HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MO
Mailing Address - Zip Code:65619-9441
Mailing Address - Country:US
Mailing Address - Phone:417-780-5050
Mailing Address - Fax:417-780-5055
Practice Address - Street 1:6129 WEST US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MO
Practice Address - Zip Code:65619
Practice Address - Country:US
Practice Address - Phone:417-708-5050
Practice Address - Fax:417-708-5055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI LTC PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-24
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1835G0303X
MO20170403113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR242178407Medicaid
MO600049471Medicaid