Provider Demographics
NPI:1558588657
Name:ARCADIA EGO INC
Entity Type:Organization
Organization Name:ARCADIA EGO INC
Other - Org Name:MITCHELL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-888-9094
Mailing Address - Street 1:123 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2051
Mailing Address - Country:US
Mailing Address - Phone:573-888-9094
Mailing Address - Fax:573-888-5946
Practice Address - Street 1:123 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2051
Practice Address - Country:US
Practice Address - Phone:573-888-9094
Practice Address - Fax:573-888-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20050357533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2608149OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO600745400Medicaid