Provider Demographics
NPI:1003849316
Name:MEDKIN PHARMACY LLC
Entity Type:Organization
Organization Name:MEDKIN PHARMACY LLC
Other - Org Name:MEDICINE CABINET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HEWKIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-308-5033
Mailing Address - Street 1:105 PROGRESS PKWY
Mailing Address - Street 2:MEDICINE CABINET PHARMACY
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2359
Mailing Address - Country:US
Mailing Address - Phone:573-860-3600
Mailing Address - Fax:573-860-2636
Practice Address - Street 1:105 PROGRESS PKWY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:573-860-3600
Practice Address - Fax:573-860-2636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDKIN PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5100333600000X
MO20030017063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6060000701Medicaid
MO626000707Medicaid
MO5100OtherMO BOARD OF PHARMA
MO6268140001Medicare NSC