Provider Demographics
NPI:1245367911
Name:GARDNER PHARMACY SERVICES, INC.
Entity type:Organization
Organization Name:GARDNER PHARMACY SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXEX. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:660-258-2122
Mailing Address - Street 1:206 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-1644
Mailing Address - Country:US
Mailing Address - Phone:660-258-2122
Mailing Address - Fax:660-258-7338
Practice Address - Street 1:206 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-1644
Practice Address - Country:US
Practice Address - Phone:660-258-2122
Practice Address - Fax:660-258-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042291332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625350608Medicaid
MO625350608Medicaid