Provider Demographics
NPI:1770655391
Name:QUEEN CITY PHARMACIES, LLC
Entity Type:Organization
Organization Name:QUEEN CITY PHARMACIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHREIBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-965-5506
Mailing Address - Street 1:811 E. DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-3114
Mailing Address - Country:US
Mailing Address - Phone:417-866-3054
Mailing Address - Fax:417-866-1250
Practice Address - Street 1:811 E. DIVISION STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-3114
Practice Address - Country:US
Practice Address - Phone:417-866-3054
Practice Address - Fax:417-866-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332B00000X
MO005536333600000X
333600000X, 3336C0003X
MO201703117D3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2628494OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO601741507Medicaid
MO601741507Medicaid
MO0620650001Medicare NSC