Provider Demographics
NPI:1932179579
Name:GILLEN PHARMACY INC
Entity Type:Organization
Organization Name:GILLEN PHARMACY INC
Other - Org Name:GILLEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:816-884-4559
Mailing Address - Street 1:2820 E ROCK HAVEN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-4413
Mailing Address - Country:US
Mailing Address - Phone:816-884-5115
Mailing Address - Fax:816-884-4559
Practice Address - Street 1:2820 E ROCK HAVEN RD STE 110
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-4413
Practice Address - Country:US
Practice Address - Phone:816-884-5115
Practice Address - Fax:816-884-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20020164843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600309702Medicaid
2048908OtherPK