Provider Demographics
NPI:1356551592
Name:LETASSY PHARMACY
Entity type:Organization
Organization Name:LETASSY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LETASSY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-785-8421
Mailing Address - Street 1:1014 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4840
Mailing Address - Country:US
Mailing Address - Phone:573-785-8421
Mailing Address - Fax:573-785-3348
Practice Address - Street 1:1014 W PINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4840
Practice Address - Country:US
Practice Address - Phone:573-785-8421
Practice Address - Fax:573-785-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO026011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601504202Medicaid
MO2618568OtherNAPD
MO0587420001Medicare NSC