Provider Demographics
NPI:1619982246
Name:COLE CAMP PHARMACY INC
Entity Type:Organization
Organization Name:COLE CAMP PHARMACY INC
Other - Org Name:COLE CAMP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-668-4646
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:COLE CAMP
Mailing Address - State:MO
Mailing Address - Zip Code:65325-0100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:COLE CAMP
Practice Address - State:MO
Practice Address - Zip Code:65325-1120
Practice Address - Country:US
Practice Address - Phone:660-668-4646
Practice Address - Fax:660-668-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0064763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2632075OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO603807603Medicaid