Provider Demographics
NPI:1477761336
Name:WESTERN MISSOURI MEDICAL CENTER OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:WESTERN MISSOURI MEDICAL CENTER OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:OHMART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-262-7307
Mailing Address - Street 1:403 BURKARTH RD
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3101
Mailing Address - Country:US
Mailing Address - Phone:660-747-2500
Mailing Address - Fax:660-429-2300
Practice Address - Street 1:403 BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093
Practice Address - Country:US
Practice Address - Phone:660-747-2500
Practice Address - Fax:660-429-2300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MISSOURI MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006035150183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606090009Medicaid
MO2003015598OtherSTATE LICENSE #
MO12543918OtherSTATE TAX ID
MOBW8431811OtherDEA REGISTRATION