Provider Demographics
NPI:1922032903
Name:CURATORS OF THE UNIVERSITY OF MISSOURI
Entity Type:Organization
Organization Name:CURATORS OF THE UNIVERSITY OF MISSOURI
Other - Org Name:MIZZOU PHARMACY - VERSAILLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANSOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-884-0054
Mailing Address - Street 1:901 KIDWELL DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084
Mailing Address - Country:US
Mailing Address - Phone:573-378-4661
Mailing Address - Fax:573-378-5053
Practice Address - Street 1:901 KIDWELL DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084
Practice Address - Country:US
Practice Address - Phone:573-378-4661
Practice Address - Fax:573-378-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0031973336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600383608Medicaid
MO0454810001Medicare ID - Type Unspecified