Provider Demographics
NPI:1437789237
Name:OLD TOWN PHARMACY LLC
Entity Type:Organization
Organization Name:OLD TOWN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-635-1100
Mailing Address - Street 1:100 CHAPEL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-9378
Mailing Address - Country:US
Mailing Address - Phone:417-635-1100
Mailing Address - Fax:
Practice Address - Street 1:100 CHAPEL DR STE A
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-9378
Practice Address - Country:US
Practice Address - Phone:417-635-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy