Provider Demographics
NPI:1578754701
Name:OLD TOWN PHARMACY LLC
Entity Type:Organization
Organization Name:OLD TOWN PHARMACY LLC
Other - Org Name:OLD TOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:417-635-1100
Mailing Address - Street 1:100A CHAPEL DR
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708
Mailing Address - Country:US
Mailing Address - Phone:417-635-1100
Mailing Address - Fax:417-635-1103
Practice Address - Street 1:100A CHAPEL DRIVE
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708
Practice Address - Country:US
Practice Address - Phone:417-635-1100
Practice Address - Fax:417-635-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070224973336C0003X
MO20140108473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007022497OtherPHARMACY LIC
2637506OtherNCPDP
MO19735928Medicaid
FO0411897OtherDEA
MO19735928Medicaid