Provider Demographics
NPI:1184059784
Name:TIM MITCHELL MEDICAL, INC
Entity type:Organization
Organization Name:TIM MITCHELL MEDICAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-451-3776
Mailing Address - Street 1:719 S NEOSHO BLVD
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2051
Mailing Address - Country:US
Mailing Address - Phone:417-455-1883
Mailing Address - Fax:417-455-2781
Practice Address - Street 1:115 E HICKORY ST
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-1806
Practice Address - Country:US
Practice Address - Phone:417-451-3776
Practice Address - Fax:417-451-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600003470Medicaid
MO600003470Medicaid
MOMA4714Medicare PIN