Provider Demographics
NPI:1396198818
Name:PLATZ ENTERPRISES INC.
Entity Type:Organization
Organization Name:PLATZ ENTERPRISES INC.
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS SPECIALIST, LICENSING/CO
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:573-885-0885
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-0528
Mailing Address - Country:US
Mailing Address - Phone:573-885-0885
Mailing Address - Fax:573-677-0567
Practice Address - Street 1:1409 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1945
Practice Address - Country:US
Practice Address - Phone:660-542-2020
Practice Address - Fax:660-542-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0021903336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600122303Medicaid
2162061OtherPK