Provider Demographics
NPI:1376569228
Name:CITY PBA PHARMACY
Entity Type:Organization
Organization Name:CITY PBA PHARMACY
Other - Org Name:CITY PBA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESSIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:660-529-2255
Mailing Address - Street 1:227 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SLATER
Mailing Address - State:MO
Mailing Address - Zip Code:65349-1411
Mailing Address - Country:US
Mailing Address - Phone:660-529-2255
Mailing Address - Fax:660-529-2701
Practice Address - Street 1:227 MAIN ST
Practice Address - Street 2:
Practice Address - City:SLATER
Practice Address - State:MO
Practice Address - Zip Code:65349-1411
Practice Address - Country:US
Practice Address - Phone:660-529-2255
Practice Address - Fax:660-529-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0039193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600095418Medicaid
2048676OtherPK
2604393OtherOTHER ID NUMBER-COMMERCIAL NUMBER