Provider Demographics
NPI:1043308497
Name:ST. JOHN'S CLINIC INC
Entity Type:Organization
Organization Name:ST. JOHN'S CLINIC INC
Other - Org Name:ST. JOHN'S PHARMACY-ROLLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RETAIL PHARMACY COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-820-6624
Mailing Address - Street 1:1100 WEST 10TH STREET
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:573-426-4931
Mailing Address - Fax:573-426-4932
Practice Address - Street 1:1100 WEST 10TH STREET
Practice Address - Street 2:SUITE 150
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-426-4931
Practice Address - Fax:573-426-4932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006027507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid