Provider Demographics
NPI:1346316007
Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Entity Type:Organization
Organization Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Other - Org Name:DICUS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-5703
Mailing Address - Street 1:210 E MURTA ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1018
Mailing Address - Country:US
Mailing Address - Phone:573-783-2788
Mailing Address - Fax:537-783-7899
Practice Address - Street 1:210 E MURTA ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1018
Practice Address - Country:US
Practice Address - Phone:573-783-2788
Practice Address - Fax:537-783-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0061483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048865OtherPK
MO601894405Medicaid
MO601894405Medicaid