Provider Demographics
NPI:1619043379
Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Entity Type:Organization
Organization Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Other - Org Name:DICUS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-5703
Mailing Address - Street 1:125 W KARSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2156
Mailing Address - Country:US
Mailing Address - Phone:573-756-5425
Mailing Address - Fax:573-756-7455
Practice Address - Street 1:125 W KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2156
Practice Address - Country:US
Practice Address - Phone:573-756-5425
Practice Address - Fax:573-756-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20030096713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO60093207Medicaid
2048856OtherPK
2048856OtherPK