Provider Demographics
NPI:1013089804
Name:QUEEN CITY PHARMACIES, LLC
Entity Type:Organization
Organization Name:QUEEN CITY PHARMACIES, LLC
Other - Org Name:MEDICENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-881-8841
Mailing Address - Street 1:1474 N BOONVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-1806
Mailing Address - Country:US
Mailing Address - Phone:417-869-1866
Mailing Address - Fax:417-869-6601
Practice Address - Street 1:1474 N BOONVILLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1806
Practice Address - Country:US
Practice Address - Phone:417-869-1866
Practice Address - Fax:417-869-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0065373336C0003X
MO20170311693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2603810OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO600051320Medicaid
MO600051320Medicaid
2603810OtherNCPDP PROVIDER IDENTIFICATION NUMBER