Provider Demographics
NPI:1295035327
Name:HOMETOWN PHARMACY MANAGEMENT LLC
Entity Type:Organization
Organization Name:HOMETOWN PHARMACY MANAGEMENT LLC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/PHARMACIST IN CHARG
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-996-5118
Mailing Address - Street 1:110 LEROUX STREET
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-0000
Mailing Address - Country:US
Mailing Address - Phone:573-996-4000
Mailing Address - Fax:573-996-3239
Practice Address - Street 1:110 LEROUX STREET
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-0000
Practice Address - Country:US
Practice Address - Phone:573-996-4000
Practice Address - Fax:573-996-3239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1295035327Medicaid
MO1295035327Medicaid