Provider Demographics
NPI:1912101031
Name:PRATT'S REXALL DRUGS, INC.
Entity Type:Organization
Organization Name:PRATT'S REXALL DRUGS, INC.
Other - Org Name:PRATT'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIMANN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-237-3321
Mailing Address - Street 1:100 DWAYNE VON BERHEN DR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MO
Mailing Address - Zip Code:63068-3207
Mailing Address - Country:US
Mailing Address - Phone:573-237-3321
Mailing Address - Fax:573-237-2005
Practice Address - Street 1:100 DWAYNE VON BERHEN DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068-3207
Practice Address - Country:US
Practice Address - Phone:573-237-3321
Practice Address - Fax:573-237-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600447003Medicaid
MO600447003Medicaid