Provider Demographics
NPI:1184217077
Name:MISSOURI DELTA MEDICAL CENTER SIKESTON PHARMACY
Entity type:Organization
Organization Name:MISSOURI DELTA MEDICAL CENTER SIKESTON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MAURA
Authorized Official - Middle Name:ELIS
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-472-7423
Mailing Address - Street 1:102 HOSPITALITY DR
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801
Mailing Address - Country:US
Mailing Address - Phone:573-471-1600
Mailing Address - Fax:
Practice Address - Street 1:102 HOSPITALITY DR
Practice Address - Street 2:UNIT B
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-838-2700
Practice Address - Fax:573-838-2701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI DELTA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-11
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy