Basic Information
| Provider Information | |||||||||
| NPI: | 1255302451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITIZENS MEMORIAL HEALTH CARE FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CITIZENS MEMORIAL HME PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266000 | ||||||||
| FaxNumber: | 4173286242 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301B N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266003 | ||||||||
| FaxNumber: | 4177775806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4173286258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 2002031026 | MO | Y | Suppliers | Pharmacy |
No ID Information.