Provider Demographics
NPI:1952554693
Name:PRESCRIPTION DRUG STORE
Entity Type:Organization
Organization Name:PRESCRIPTION DRUG STORE
Other - Org Name:PRESCRIPTION DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-333-4890
Mailing Address - Street 1:410 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1451
Mailing Address - Country:US
Mailing Address - Phone:573-333-4890
Mailing Address - Fax:573-333-0306
Practice Address - Street 1:410 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-4890
Practice Address - Fax:573-333-0306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESCRIPTION DRUG STORE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-28
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620126102Medicaid
MO620126102Medicaid