Provider Demographics
NPI:1750763322
Name:PUTNAM COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:PUTNAM COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLABAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-947-3673
Mailing Address - Street 1:1926 OAK ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63565-1180
Mailing Address - Country:US
Mailing Address - Phone:660-947-2574
Mailing Address - Fax:660-947-2576
Practice Address - Street 1:1926 OAK ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1180
Practice Address - Country:US
Practice Address - Phone:660-947-2574
Practice Address - Fax:660-947-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2019-11-18
Deactivation Date:2018-07-24
Deactivation Code:
Reactivation Date:2019-11-18
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
MO20150193653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152660OtherPK