Provider Demographics
NPI:1861488660
Name:DEJACE ENTERPRISES INC
Entity Type:Organization
Organization Name:DEJACE ENTERPRISES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTERKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-898-2550
Mailing Address - Street 1:106A BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ELSBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:63343-1233
Mailing Address - Country:US
Mailing Address - Phone:573-898-2550
Mailing Address - Fax:573-898-5730
Practice Address - Street 1:106A BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ELSBERRY
Practice Address - State:MO
Practice Address - Zip Code:63343-1233
Practice Address - Country:US
Practice Address - Phone:573-898-2550
Practice Address - Fax:573-898-5730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WD0400X, 3336C0003X, 3336L0003X
MO029059332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601684608Medicaid
MO62184604Medicaid
MO62184604Medicaid