Provider Demographics
NPI:1285645820
Name:MOUNTAIN GROVE PHARMACY INC
Entity Type:Organization
Organization Name:MOUNTAIN GROVE PHARMACY INC
Other - Org Name:MOUNTAIN GROVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-926-9655
Mailing Address - Street 1:106 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1724
Mailing Address - Country:US
Mailing Address - Phone:417-926-4156
Mailing Address - Fax:417-926-4125
Practice Address - Street 1:106 N UNION ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1724
Practice Address - Country:US
Practice Address - Phone:417-926-4156
Practice Address - Fax:417-926-4125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20150065693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601091507Medicaid
2049297OtherPK
MO601091507Medicaid