Provider Demographics
NPI:1558492421
Name:CAMDENTON MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:CAMDENTON MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-346-2300
Mailing Address - Street 1:1930 NORTH STATE HWY 5
Mailing Address - Street 2:UNIT 1C
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-1930
Mailing Address - Country:US
Mailing Address - Phone:573-346-2300
Mailing Address - Fax:573-346-8409
Practice Address - Street 1:1930 NORTH STATE HWY 5
Practice Address - Street 2:UNIT 1C
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-1930
Practice Address - Country:US
Practice Address - Phone:573-346-2300
Practice Address - Fax:573-346-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO028456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO29193OtherBNDD
MO2629422OtherNABP
MO2629422OtherNABP