Provider Demographics
NPI:1164284634
Name:MAIN STREET RX, LLC
Entity Type:Organization
Organization Name:MAIN STREET RX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-649-9229
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63845-1136
Mailing Address - Country:US
Mailing Address - Phone:573-649-9229
Mailing Address - Fax:
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1136
Practice Address - Country:US
Practice Address - Phone:573-649-9229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy