Provider Demographics
NPI:1700976594
Name:MEDLEY PHARMACY INC
Entity Type:Organization
Organization Name:MEDLEY PHARMACY INC
Other - Org Name:SINKS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOCAL HEALTH
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSOURI INC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-0885
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-0528
Mailing Address - Country:US
Mailing Address - Phone:573-885-0885
Mailing Address - Fax:573-677-0567
Practice Address - Street 1:206 S ALVARADO AVE STE D
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013-2544
Practice Address - Country:US
Practice Address - Phone:573-859-3100
Practice Address - Fax:573-859-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
MO20050003213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO608602108Medicaid
MO628602104Medicaid
2047587OtherPK
2047587OtherPK