Provider Demographics
NPI:1396811055
Name:TOWN AND COUNTRY GROCERS OF FREDERICKSTOWN MO INC
Entity type:Organization
Organization Name:TOWN AND COUNTRY GROCERS OF FREDERICKSTOWN MO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-783-5703
Mailing Address - Street 1:3106 SOUTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8404
Mailing Address - Country:US
Mailing Address - Phone:870-933-2016
Mailing Address - Fax:870-933-2031
Practice Address - Street 1:3106 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8404
Practice Address - Country:US
Practice Address - Phone:870-933-2016
Practice Address - Fax:870-933-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR200213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131300407Medicaid
1988202OtherPK