Provider Demographics
NPI:1952382913
Name:TOWN & COUNTRY SUPER MARKET INC
Entity Type:Organization
Organization Name:TOWN & COUNTRY SUPER MARKET INC
Other - Org Name:COUNTRY MART PHARMACY #2425
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-729-4091
Mailing Address - Street 1:1204 E HIGHWAY 32
Mailing Address - Street 2:PO BOX 748
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-2844
Mailing Address - Country:US
Mailing Address - Phone:573-729-4091
Mailing Address - Fax:573-729-2394
Practice Address - Street 1:43 EAST HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:STEELVILLE
Practice Address - State:MO
Practice Address - Zip Code:65565
Practice Address - Country:US
Practice Address - Phone:573-775-4666
Practice Address - Fax:573-775-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006587332B00000X
MO2005398223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO604623405Medicaid
MO624623401Medicaid
MO1242930002Medicare NSC