Provider Demographics
NPI:1295366797
Name:MAIN STREET RX
Entity Type:Organization
Organization Name:MAIN STREET RX
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-335-8207
Mailing Address - Street 1:37 DOCTORS PARK STE 2
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4903
Mailing Address - Country:US
Mailing Address - Phone:573-334-4432
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:2020-02-03
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy