Provider Demographics
NPI:1093706632
Name:MEDLEY PHARMACY INC
Entity Type:Organization
Organization Name:MEDLEY PHARMACY INC
Other - Org Name:SINKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOCAL HEALTH
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSOURI INC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-0885
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453
Mailing Address - Country:US
Mailing Address - Phone:573-885-0885
Mailing Address - Fax:573-885-0882
Practice Address - Street 1:1204 E HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2844
Practice Address - Country:US
Practice Address - Phone:573-729-4091
Practice Address - Fax:573-729-2394
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDLEY PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-02
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006425332B00000X
332B00000X, 3336C0003X
MO64253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO603779703Medicaid
MO623779709Medicaid
MO1242930001Medicare NSC