Provider Demographics
NPI:1336343227
Name:ADVANTAGE PHARMACY, LLC
Entity Type:Organization
Organization Name:ADVANTAGE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BLACKFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:816-918-6467
Mailing Address - Street 1:301 E PRICE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-2482
Mailing Address - Country:US
Mailing Address - Phone:816-324-1229
Mailing Address - Fax:816-326-9012
Practice Address - Street 1:301 E PRICE AVE STE B
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:MO
Practice Address - Zip Code:64485-2482
Practice Address - Country:US
Practice Address - Phone:816-324-1229
Practice Address - Fax:816-326-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070164583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007016458OtherMO PHARMACY LICENSE NUM
MO5998860001Medicare NSC