Provider Demographics
NPI:1851426852
Name:FAMILY PHARMACY OF MOUNTAIN GROVE LLC
Entity Type:Organization
Organization Name:FAMILY PHARMACY OF MOUNTAIN GROVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-926-4156
Mailing Address - Street 1:1600 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1010
Mailing Address - Country:US
Mailing Address - Phone:417-926-9655
Mailing Address - Fax:417-926-0045
Practice Address - Street 1:1600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1010
Practice Address - Country:US
Practice Address - Phone:417-926-9655
Practice Address - Fax:417-926-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MO2000596843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625201207Medicaid
MO605201201Medicaid
MO4051290001Medicare NSC