Provider Demographics
NPI:1477518355
Name:ADVANCED HEALTHCARE MANAGEMENT SERVICES, LLC
Entity Type:Organization
Organization Name:ADVANCED HEALTHCARE MANAGEMENT SERVICES, LLC
Other - Org Name:ADVANCED HEALTHCARE PHARMACY I
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:P.O. BOX 989
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0989
Mailing Address - Country:US
Mailing Address - Phone:573-778-1608
Mailing Address - Fax:573-778-1645
Practice Address - Street 1:2002 KANELL BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4045
Practice Address - Country:US
Practice Address - Phone:573-778-1608
Practice Address - Fax:573-778-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020101863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO605768605Medicaid
5262580004Medicare NSC