Provider Demographics
NPI:1790978765
Name:ST. JOHN'S PHYSICIAN & CLINIC
Entity Type:Organization
Organization Name:ST. JOHN'S PHYSICIAN & CLINIC
Other - Org Name:ST. JOHN'S SISK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RETAIL COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-6624
Mailing Address - Street 1:101 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542
Mailing Address - Country:US
Mailing Address - Phone:573-674-2922
Mailing Address - Fax:573-674-4334
Practice Address - Street 1:101 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542
Practice Address - Country:US
Practice Address - Phone:573-674-2922
Practice Address - Fax:573-674-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty