Provider Demographics
NPI:1790063428
Name:MILLER REXALL DRUG, INC.
Entity Type:Organization
Organization Name:MILLER REXALL DRUG, INC.
Other - Org Name:MILLER REXALL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:MIGNON
Authorized Official - Last Name:KLINGSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:660-385-2167
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-0486
Mailing Address - Country:US
Mailing Address - Phone:660-385-2167
Mailing Address - Fax:660-385-6245
Practice Address - Street 1:115 VINE STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1654
Practice Address - Country:US
Practice Address - Phone:660-385-2167
Practice Address - Fax:660-385-6245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLER REXALL DRUG, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-29
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008030097332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600122402Medicaid
6235510001Medicare NSC
MO6235510001Medicare NSC