Provider Demographics
NPI:1326187212
Name:ST OF MO FULTON ST HOSP
Entity Type:Organization
Organization Name:ST OF MO FULTON ST HOSP
Other - Org Name:FULTON STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BOECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4055
Mailing Address - Street 1:600 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1753
Mailing Address - Country:US
Mailing Address - Phone:573-592-3062
Mailing Address - Fax:573-592-3070
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-592-3062
Practice Address - Fax:573-592-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0018973336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049691OtherPK