Provider Demographics
NPI:1518347780
Name:SUMMERS PHARMACY
Entity Type:Organization
Organization Name:SUMMERS PHARMACY
Other - Org Name:SUMMERS PHARMACY #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:660-885-3034
Mailing Address - Street 1:605 PAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-2757
Mailing Address - Country:US
Mailing Address - Phone:660-885-3034
Mailing Address - Fax:660-885-5888
Practice Address - Street 1:913 W FORT SCOTT STREET
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-2007
Practice Address - Country:US
Practice Address - Phone:660-679-5002
Practice Address - Fax:660-679-5003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMERS PHARMACY ENTERPRISES, CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-03
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150167663336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600022539Medicaid