Provider Demographics
NPI:1356455778
Name:TEACO, INC
Entity Type:Organization
Organization Name:TEACO, INC
Other - Org Name:TEKO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:JERID
Authorized Official - Middle Name:E
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-888-6673
Mailing Address - Street 1:501 TEACO RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3721
Mailing Address - Country:US
Mailing Address - Phone:573-888-6673
Mailing Address - Fax:
Practice Address - Street 1:501 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3721
Practice Address - Country:US
Practice Address - Phone:573-888-6673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO60095005Medicaid
2617225OtherNCPDP
MO2004011813OtherSTATE LICENSE #
2617225OtherNCPDP