Provider Demographics
NPI:1952876948
Name:FOUR STATES APOTHECARY LLC
Entity Type:Organization
Organization Name:FOUR STATES APOTHECARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:417-529-1815
Mailing Address - Street 1:413 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:KS
Mailing Address - Zip Code:67356-2017
Mailing Address - Country:US
Mailing Address - Phone:620-795-2233
Mailing Address - Fax:620-795-4910
Practice Address - Street 1:102 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CARL JUNCTION
Practice Address - State:MO
Practice Address - Zip Code:64834-1000
Practice Address - Country:US
Practice Address - Phone:417-649-7021
Practice Address - Fax:417-649-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy