Provider Demographics
NPI:1598879561
Name:MARSHFIELD CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:MARSHFIELD CLINIC PHARMACY LLC
Other - Org Name:MARSHFIELD CLINIC PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VINEHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-468-4442
Mailing Address - Street 1:483 POMME DE TERRE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-2386
Mailing Address - Country:US
Mailing Address - Phone:417-468-4442
Mailing Address - Fax:417-468-4462
Practice Address - Street 1:483 POMME DE TERRE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2386
Practice Address - Country:US
Practice Address - Phone:417-468-4442
Practice Address - Fax:417-468-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MO20040360653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2629117OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO626937908Medicaid
MO606937902Medicaid