Provider Demographics
NPI:1700020112
Name:ROZIERS COUNTRY MART
Entity Type:Organization
Organization Name:ROZIERS COUNTRY MART
Other - Org Name:COUNTRY MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-883-3524
Mailing Address - Street 1:190 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-1828
Mailing Address - Country:US
Mailing Address - Phone:573-883-3524
Mailing Address - Fax:573-883-7991
Practice Address - Street 1:190 PLAZA DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1828
Practice Address - Country:US
Practice Address - Phone:573-883-3524
Practice Address - Fax:573-883-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20090077713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120051OtherPK
MO601586605Medicaid