Provider Demographics
NPI:1679548523
Name:FAMILY PHARMACY OF MISSOURI LLC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MISSOURI LLC
Other - Org Name:FAMILY PHARMACY #5
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-581-4335
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-0515
Mailing Address - Country:US
Mailing Address - Phone:417-753-2046
Mailing Address - Fax:417-753-2047
Practice Address - Street 1:432 S MILL ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-7601
Practice Address - Country:US
Practice Address - Phone:417-753-2046
Practice Address - Fax:417-753-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
MO5819333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2629713OtherNCPDP
MO620058057OtherMEDICAID DME
MO600058051Medicaid
4477450002Medicare ID - Type Unspecified
6045300003Medicare NSC