Basic Information
| Provider Information | |||||||||
| NPI: | 1942316708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARROLL CNTY MEM HOSP PHARMACY INC | ||||||||
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| OtherOrganizationName: | CARROLL COUNTY MEM HOSP PHCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | 6605420363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOVER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6605421695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336I0012X | 21044 | MO | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2623266 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 0909150 | 05 | MO | MEDICAID |