Provider Demographics
NPI:1497890529
Name:DAUGHERTY PHARMACIES LLC
Entity Type:Organization
Organization Name:DAUGHERTY PHARMACIES LLC
Other - Org Name:STANLEYS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-468-2530
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706
Mailing Address - Country:US
Mailing Address - Phone:417-468-2530
Mailing Address - Fax:
Practice Address - Street 1:1369 SPUR DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2311
Practice Address - Country:US
Practice Address - Phone:417-468-2530
Practice Address - Fax:417-859-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MO20040360663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600663405Medicaid
2047692OtherPK
MO620663401Medicaid
MO600663405Medicaid