Provider Demographics
NPI:1740352533
Name:CRAIN MOXEY PHARM INC
Entity type:Organization
Organization Name:CRAIN MOXEY PHARM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ERNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOXEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-472-2622
Mailing Address - Street 1:613 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:613 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3041
Practice Address - Country:US
Practice Address - Phone:573-472-2622
Practice Address - Fax:573-472-2623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003799320900000X, 332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621176908Medicaid
2617578OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO851176909Medicaid
MO601176902Medicaid
MO601176902Medicaid
MO1249670001Medicare NSC