Provider Demographics
NPI:1013224047
Name:FAMILY PHARMACY INC.
Entity Type:Organization
Organization Name:FAMILY PHARMACY INC.
Other - Org Name:FAMILY PHARMACY #25
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-581-4335
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-0326
Mailing Address - Country:US
Mailing Address - Phone:417-683-1760
Mailing Address - Fax:417-683-1768
Practice Address - Street 1:916 N.W. 12TH AVE
Practice Address - Street 2:SUITE F
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-683-1760
Practice Address - Fax:417-683-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
MO20100311653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1013224047Medicaid
2639257OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0344070009Medicare NSC