Provider Demographics
NPI:1497254809
Name:LA PLATA PHARMACY LLC
Entity Type:Organization
Organization Name:LA PLATA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PROKUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-346-0449
Mailing Address - Street 1:221 N. MACON STREET
Mailing Address - Street 2:
Mailing Address - City:BEVIER
Mailing Address - State:MO
Mailing Address - Zip Code:63532
Mailing Address - Country:US
Mailing Address - Phone:660-346-0449
Mailing Address - Fax:660-773-5529
Practice Address - Street 1:221 N MACON ST
Practice Address - Street 2:
Practice Address - City:BEVIER
Practice Address - State:MO
Practice Address - Zip Code:63532-1058
Practice Address - Country:US
Practice Address - Phone:660-346-0449
Practice Address - Fax:660-773-5529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018004056333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600133003Medicaid
2175841OtherPK