Provider Demographics
NPI:1205902962
Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Entity type:Organization
Organization Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-5703
Mailing Address - Street 1:801 HIGHWAY 463 N
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472-1636
Mailing Address - Country:US
Mailing Address - Phone:870-483-8015
Mailing Address - Fax:870-483-8015
Practice Address - Street 1:801 HIGHWAY 463 N
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472-1636
Practice Address - Country:US
Practice Address - Phone:870-483-8015
Practice Address - Fax:870-483-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR202623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142058407Medicaid
1988319OtherPK