Provider Demographics
NPI:1629295563
Name:FAMILY PHARMACY
Entity Type:Organization
Organization Name:FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOLTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-564-2273
Mailing Address - Street 1:806 N STURGEON ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-1426
Mailing Address - Country:US
Mailing Address - Phone:573-564-2273
Mailing Address - Fax:573-564-5249
Practice Address - Street 1:806 N STURGEON ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-1426
Practice Address - Country:US
Practice Address - Phone:573-564-2273
Practice Address - Fax:573-564-5249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO622645505Medicaid
MO622645505Medicaid