Provider Demographics
NPI:1609120484
Name:CAPE PHARMACY LLC
Entity Type:Organization
Organization Name:CAPE PHARMACY LLC
Other - Org Name:MEDICENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/VP-FINANCE & ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-965-4700
Mailing Address - Street 1:465 S MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4926
Mailing Address - Country:US
Mailing Address - Phone:573-651-5250
Mailing Address - Fax:573-651-5230
Practice Address - Street 1:465 S MOUNT AUBURN RD STE 101
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4931
Practice Address - Country:US
Practice Address - Phone:573-651-5250
Practice Address - Fax:573-651-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120419493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600002981Medicaid
2138274OtherPK
MO600002981Medicaid