Provider Demographics
NPI:1437650835
Name:TIM MITCHELL MEDICAL, INC
Entity Type:Organization
Organization Name:TIM MITCHELL MEDICAL, INC
Other - Org Name:MITCHELL'S LONG TERM CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-451-9501
Mailing Address - Street 1:719 S NEOSHO BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2051
Mailing Address - Country:US
Mailing Address - Phone:417-455-1883
Mailing Address - Fax:417-455-2781
Practice Address - Street 1:719 S NEOSHO BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-2051
Practice Address - Country:US
Practice Address - Phone:417-451-9501
Practice Address - Fax:417-455-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030277403336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602932303Medicaid