Provider Demographics
NPI:1538134945
Name:FAMILY PHARMACY OF MISSOURI LLC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MISSOURI LLC
Other - Org Name:FAMILY PHARMACY #4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-581-4335
Mailing Address - Street 1:PO BOX 2403
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737-2403
Mailing Address - Country:US
Mailing Address - Phone:417-272-8966
Mailing Address - Fax:417-272-8969
Practice Address - Street 1:18192 BUSINESS 13 STE A
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-8637
Practice Address - Country:US
Practice Address - Phone:417-272-8966
Practice Address - Fax:417-272-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MO4079333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620058032Medicaid
MO2617302OtherNCPDP
MO600058036Medicaid
MO620058032OtherMEDICAID DME
MO620058032OtherMEDICAID DME
MO4477450004Medicare ID - Type Unspecified