Provider Demographics
NPI:1639126139
Name:GARDNER PHARMACY SERVICES INC
Entity Type:Organization
Organization Name:GARDNER PHARMACY SERVICES INC
Other - Org Name:GREEN HILLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-258-2122
Mailing Address - Street 1:712 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2307
Mailing Address - Country:US
Mailing Address - Phone:660-258-2122
Mailing Address - Fax:660-258-7338
Practice Address - Street 1:712 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2307
Practice Address - Country:US
Practice Address - Phone:660-258-2122
Practice Address - Fax:660-258-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336M0002X
MO20010217863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048722OtherPK
MO605350602Medicaid
4918710001Medicare NSC