Provider Demographics
NPI:1295260818
Name:LEGACY DRUGSTORE 2, LLC
Entity type:Organization
Organization Name:LEGACY DRUGSTORE 2, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:314-605-7340
Mailing Address - Street 1:609 STATE HIGHWAY 47
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 STATE HIGHWAY 47
Practice Address - Street 2:SUITE B
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383
Practice Address - Country:US
Practice Address - Phone:314-605-7340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY CIRCLE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy