Provider Demographics
NPI:1629076377
Name:DALECO INC
Entity Type:Organization
Organization Name:DALECO INC
Other - Org Name:USA CLINIC AT MINERAL AREA HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SERVICES COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-296-3311
Mailing Address - Street 1:1401 S BOULDER AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-3647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3352
Practice Address - Country:US
Practice Address - Phone:573-756-6117
Practice Address - Fax:573-756-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080358663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2624941OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4865760005Medicare NSC