Provider Demographics
NPI:1134282429
Name:HOMETOWN PHARMACY
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:SKYE
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-759-2230
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:206 WEST 2ND STREET
Mailing Address - City:DIXON
Mailing Address - State:MO
Mailing Address - Zip Code:65459-0220
Mailing Address - Country:US
Mailing Address - Phone:573-759-2230
Mailing Address - Fax:573-759-3131
Practice Address - Street 1:206 WEST 2ND STREET
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:MO
Practice Address - Zip Code:65459-0220
Practice Address - Country:US
Practice Address - Phone:573-759-2230
Practice Address - Fax:573-759-3131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5534333600000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO603728205Medicaid