Provider Demographics
NPI:1942316708
Name:CARROLL CNTY MEM HOSP PHARMACY INC
Entity Type:Organization
Organization Name:CARROLL CNTY MEM HOSP PHARMACY INC
Other - Org Name:CARROLL COUNTY MEM HOSP PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-542-1695
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-1695
Practice Address - Fax:660-542-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO210443336I0012X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2623266OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO0909150Medicaid
MO0909150Medicaid