Provider Demographics
NPI:1942756465
Name:C & P ALTON VENTURES LLC
Entity Type:Organization
Organization Name:C & P ALTON VENTURES LLC
Other - Org Name:ALTON DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS-PEACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-778-6807
Mailing Address - Street 1:450 COUNTY ROAD 139
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:MO
Mailing Address - Zip Code:65606-8221
Mailing Address - Country:US
Mailing Address - Phone:417-778-6807
Mailing Address - Fax:
Practice Address - Street 1:201 STATE HWY 19
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:MO
Practice Address - Zip Code:65606
Practice Address - Country:US
Practice Address - Phone:417-778-7000
Practice Address - Fax:417-778-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MO20160310743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163778OtherPK
MO600035662Medicaid