Provider Demographics
NPI:1033197041
Name:CHRISTIAN HEALTH CARE PHARMACY LLC
Entity Type:Organization
Organization Name:CHRISTIAN HEALTH CARE PHARMACY LLC
Other - Org Name:REGIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-889-6357
Mailing Address - Street 1:1328 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1328 E EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4400
Practice Address - Country:US
Practice Address - Phone:417-889-6357
Practice Address - Fax:417-823-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020071893336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146797407Medicaid
2634447OtherOTHER ID NUMBER
MO605687102Medicaid
MO605687102Medicaid