Provider Demographics
NPI:1326490376
Name:GUARDIAN PHARMACY OF MISSOURI LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF MISSOURI LLC
Other - Org Name:GUARDIAN PHARMACY OF MISSOURI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-864-5873
Mailing Address - Street 1:2107 E ROCKHURST ST STE C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-6502
Mailing Address - Country:US
Mailing Address - Phone:404-810-0094
Mailing Address - Fax:404-810-0089
Practice Address - Street 1:2107 E ROCKHURST ST STE C
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-6502
Practice Address - Country:US
Practice Address - Phone:417-864-5873
Practice Address - Fax:417-864-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-01
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160233963336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1326490376Medicaid
2166287OtherPK
2166287OtherPK