Provider Demographics
NPI:1891700423
Name:ELLIOTT PHARMACY INC
Entity Type:Organization
Organization Name:ELLIOTT PHARMACY INC
Other - Org Name:ELLIOTT HEALTHMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-665-9871
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-0072
Mailing Address - Country:US
Mailing Address - Phone:660-665-9871
Mailing Address - Fax:660-665-4332
Practice Address - Street 1:2120 N BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-5109
Practice Address - Country:US
Practice Address - Phone:660-665-9871
Practice Address - Fax:660-665-4332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0059723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600398804Medicaid
2608187OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO1026680001Medicare NSC