Basic Information
| Provider Information | |||||||||
| NPI: | 1801318472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITIZENS MEMORIAL HEALTH CARE FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | STEPHENS PHARMACY AT CMH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 S SPRINGFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656132512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266003 | ||||||||
| FaxNumber: | 4177775806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S SPRINGFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656132512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266003 | ||||||||
| FaxNumber: | 4177775806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4173286258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2169973 | 01 | PK | OTHER |