Provider Demographics
NPI:1083695902
Name:TOWN & COUNTRY SUPER MARKET INC
Entity Type:Organization
Organization Name:TOWN & COUNTRY SUPER MARKET INC
Other - Org Name:COUNTRY MART PHARMACY #2416
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-729-4091
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-0748
Mailing Address - Country:US
Mailing Address - Phone:573-729-4091
Mailing Address - Fax:573-729-2394
Practice Address - Street 1:508 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-6201
Practice Address - Country:US
Practice Address - Phone:573-759-3073
Practice Address - Fax:573-759-3560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWN & COUNTRY SUPER MARKET INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-08
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015586332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606197705Medicaid
MO626197701Medicaid
MO606197705Medicaid