Provider Demographics
NPI:1316594328
Name:LEGACY DRUGSTORE LLC
Entity Type:Organization
Organization Name:LEGACY DRUGSTORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAUMENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-791-1274
Mailing Address - Street 1:13000 VETERANS MEMORIAL PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63390-1012
Mailing Address - Country:US
Mailing Address - Phone:636-791-1274
Mailing Address - Fax:636-791-1326
Practice Address - Street 1:13000 VETERANS MEMORIAL PKWY STE A
Practice Address - Street 2:
Practice Address - City:WRIGHT CITY
Practice Address - State:MO
Practice Address - Zip Code:63390-1012
Practice Address - Country:US
Practice Address - Phone:636-791-1274
Practice Address - Fax:636-791-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy