Provider Demographics
NPI:1346718418
Name:GIDEON PHARMACY LLC
Entity Type:Organization
Organization Name:GIDEON PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-5125
Mailing Address - Street 1:2007 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5805
Mailing Address - Country:US
Mailing Address - Phone:573-334-5125
Mailing Address - Fax:
Practice Address - Street 1:111 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848
Practice Address - Country:US
Practice Address - Phone:573-448-3333
Practice Address - Fax:573-448-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053702118Medicaid