Provider Demographics
NPI:1578669701
Name:TIM MITCHELL MEDICAL, INC
Entity Type:Organization
Organization Name:TIM MITCHELL MEDICAL, INC
Other - Org Name:MITCHELL'S DRUG STORE ON THE BOULEVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-451-9501
Mailing Address - Street 1:719 S NEOSHO BLVD
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2051
Mailing Address - Country:US
Mailing Address - Phone:417-455-1883
Mailing Address - Fax:417-455-2781
Practice Address - Street 1:719 S NEOSHO BLVD
Practice Address - Street 2:STE A
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850
Practice Address - Country:US
Practice Address - Phone:417-451-9501
Practice Address - Fax:417-451-9594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
MO20030277403336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200642940AMedicaid
OK200286710AMedicaid
MO602932303Medicaid
MO622932309Medicaid