Provider Demographics
NPI:1326110396
Name:THAYER DRUG STORE LLC
Entity Type:Organization
Organization Name:THAYER DRUG STORE LLC
Other - Org Name:THAYER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GINNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-264-3784
Mailing Address - Street 1:623 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-1436
Mailing Address - Country:US
Mailing Address - Phone:417-264-3784
Mailing Address - Fax:417-264-3794
Practice Address - Street 1:623 S 6TH ST
Practice Address - Street 2:
Practice Address - City:THAYER
Practice Address - State:MO
Practice Address - Zip Code:65791-1436
Practice Address - Country:US
Practice Address - Phone:417-264-3784
Practice Address - Fax:417-264-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20060342493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049527OtherPK