Provider Demographics
NPI:1285675132
Name:ODESSA FAMILY PHARMACY
Entity Type:Organization
Organization Name:ODESSA FAMILY PHARMACY
Other - Org Name:ODESSA FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:816-633-8480
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-0108
Mailing Address - Country:US
Mailing Address - Phone:816-633-8480
Mailing Address - Fax:816-230-5675
Practice Address - Street 1:316 W 40 HWY
Practice Address - Street 2:STE A
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076
Practice Address - Country:US
Practice Address - Phone:816-633-8480
Practice Address - Fax:816-230-5675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0043383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600748503 MOMedicaid
2615194OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2615194OtherNCPDP PROVIDER IDENTIFICATION NUMBER