Provider Demographics
NPI:1033217062
Name:FAMILY PHARMACY OF MISSOURI LLC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MISSOURI LLC
Other - Org Name:FAMILY PHARMACY #20
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH MS
Authorized Official - Phone:417-581-4335
Mailing Address - Street 1:1326 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1815
Mailing Address - Country:US
Mailing Address - Phone:417-326-8747
Mailing Address - Fax:417-326-8748
Practice Address - Street 1:1326 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1815
Practice Address - Country:US
Practice Address - Phone:417-326-8747
Practice Address - Fax:417-326-8748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MO20060149083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2636934OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO606261105Medicaid
6066990001Medicare NSC