Basic Information
| Provider Information | |||||||||
| NPI: | 1609206721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL DEVELOPMENTS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CONVENIENT CARE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 525 BRANSON LANDING BLVD | ||||||||
| Address2: | SUITE 1005 | ||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656162052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173357000 | ||||||||
| FaxNumber: | 4173357003 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 BRANSON LANDING BLVD | ||||||||
| Address2: | SUITE 1005 | ||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656162052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172697470 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2013 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | LEROY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4173357700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL DEVELOPMENTS INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 2013042829 | MO | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.