Provider Demographics
NPI:1447225412
Name:FAMILY PHARMACY OF MISSOURI LLC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MISSOURI LLC
Other - Org Name:FAMILY PHARMACY #14
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-581-4335
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-1440
Mailing Address - Country:US
Mailing Address - Phone:417-724-2601
Mailing Address - Fax:417-724-2621
Practice Address - Street 1:105 S RIDGECREST AVE
Practice Address - Street 2:SUITE 1 & 2
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7807
Practice Address - Country:US
Practice Address - Phone:417-724-2601
Practice Address - Fax:417-724-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MO2004026659333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606155802Medicaid
MO626155808Medicaid
MO626155808OtherMEDICAID DME
MO2635677OtherNCPDP
MO626155808Medicaid
6045300006Medicare NSC