Provider Demographics
NPI:1144566811
Name:TIM MITCHELL MEDICAL INC
Entity Type:Organization
Organization Name:TIM MITCHELL MEDICAL INC
Other - Org Name:MITCHELL'S DOWNTOWN DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:G
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-451-3776
Mailing Address - Street 1:719 S NEOSHO BLVD
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2051
Mailing Address - Country:US
Mailing Address - Phone:417-451-3776
Mailing Address - Fax:417-451-2332
Practice Address - Street 1:115 E HICKORY ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1806
Practice Address - Country:US
Practice Address - Phone:417-451-3776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MO20120418163336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600003470Medicaid
MO600003470Medicaid