Provider Demographics
NPI:1184941684
Name:MEDLEY PHARMACY INC.
Entity type:Organization
Organization Name:MEDLEY PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-0885
Mailing Address - Street 1:330 N. FRANKLIN
Mailing Address - Street 2:PO BOX 528
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453
Mailing Address - Country:US
Mailing Address - Phone:573-885-0885
Mailing Address - Fax:573-677-0567
Practice Address - Street 1:1903 E. 9TH ST.
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683
Practice Address - Country:US
Practice Address - Phone:660-359-5700
Practice Address - Fax:660-359-5701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDLEY PHARMACY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-23
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336C0003X
MO20100176213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124771OtherPK
MO606475200Medicaid
2124771OtherPK