Provider Demographics
NPI:1093731408
Name:MACK'S GROCERY, LLC
Entity Type:Organization
Organization Name:MACK'S GROCERY, LLC
Other - Org Name:PARKERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:660-747-7449
Mailing Address - Street 1:PO BOX 1117
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-7117
Mailing Address - Country:US
Mailing Address - Phone:660-747-7449
Mailing Address - Fax:660-747-5037
Practice Address - Street 1:1047 S MAGUIRE ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-2618
Practice Address - Country:US
Practice Address - Phone:660-747-7449
Practice Address - Fax:660-747-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040071073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5071510001Medicare NSC