Provider Demographics
NPI:1689700379
Name:MAIN STREET PHARMACY LLC
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY LLC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-649-9229
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63845-1136
Mailing Address - Country:US
Mailing Address - Phone:573-649-9229
Mailing Address - Fax:573-649-9230
Practice Address - Street 1:117 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63845-1136
Practice Address - Country:US
Practice Address - Phone:573-649-9229
Practice Address - Fax:573-649-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130006743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048743OtherPK
MO605420405Medicaid
MO6821510001Medicare NSC