Provider Demographics
NPI:1518956093
Name:PLEASANT HILL DRUG STORE INC
Entity Type:Organization
Organization Name:PLEASANT HILL DRUG STORE INC
Other - Org Name:PLEASANT HILL DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFEVER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:913-515-0462
Mailing Address - Street 1:1905 N 7 HWY
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:MO
Mailing Address - Zip Code:64080-9366
Mailing Address - Country:US
Mailing Address - Phone:816-540-4000
Mailing Address - Fax:816-540-4341
Practice Address - Street 1:1905 N STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:MO
Practice Address - Zip Code:64080-9366
Practice Address - Country:US
Practice Address - Phone:816-540-4000
Practice Address - Fax:816-540-4341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20020099633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO628237802Medicaid
MO608237806Medicaid
2048807OtherPK
4488940001Medicare NSC