Provider Demographics
NPI:1518465533
Name:MISSOURI MED LLC
Entity Type:Organization
Organization Name:MISSOURI MED LLC
Other - Org Name:MISSOURI MED, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAFIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-3044
Mailing Address - Street 1:2215 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4403
Mailing Address - Country:US
Mailing Address - Phone:573-335-3044
Mailing Address - Fax:573-335-6724
Practice Address - Street 1:2215 BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4403
Practice Address - Country:US
Practice Address - Phone:573-803-5500
Practice Address - Fax:573-803-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018005320332BN1400X
333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600051690Medicaid
2176054OtherPK