Provider Demographics
NPI:1326150327
Name:MS MGC INC
Entity Type:Organization
Organization Name:MS MGC INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-564-1111
Mailing Address - Street 1:635 S STURGEON ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-2707
Mailing Address - Country:US
Mailing Address - Phone:573-564-1111
Mailing Address - Fax:573-564-2828
Practice Address - Street 1:635 S STURGEON ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-2707
Practice Address - Country:US
Practice Address - Phone:573-564-1111
Practice Address - Fax:573-564-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X
MO20030346013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2633041OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO604842302Medicaid
MO604842302Medicaid
2633041OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MOMA1111Medicare PIN