Provider Demographics
NPI:1245364066
Name:NORTHWEST PHARMACY, INC
Entity type:Organization
Organization Name:NORTHWEST PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KLEINBECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-686-6211
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-6211
Mailing Address - Fax:573-686-2219
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-6211
Practice Address - Fax:573-686-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO620059725332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620059725Medicaid
MO1902974140OtherRX NPI
MO2004019998OtherMO PHARMACY PERMIT
MO2004019998OtherMO PHARMACY PERMIT
MOBN8927406OtherDEA