Provider Demographics
NPI:1134668445
Name:MISSOURI LTC PHARMACY LLC
Entity Type:Organization
Organization Name:MISSOURI LTC PHARMACY LLC
Other - Org Name:INFINIUM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERIOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-690-4500
Mailing Address - Street 1:1617 MANUFACTURERS DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2838
Mailing Address - Country:US
Mailing Address - Phone:314-690-4500
Mailing Address - Fax:314-690-4502
Practice Address - Street 1:1617 MANUFACTURERS DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2838
Practice Address - Country:US
Practice Address - Phone:314-690-4500
Practice Address - Fax:314-690-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600043834Medicaid
2167982OtherPK