Provider Demographics
NPI:1174728745
Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MD INC
Entity type:Organization
Organization Name:TOWN & COUNTRY GROCERS OF FREDERICKTOWN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:I
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-783-2788
Mailing Address - Street 1:210 E MURTA ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1018
Mailing Address - Country:US
Mailing Address - Phone:573-783-2788
Mailing Address - Fax:573-783-7899
Practice Address - Street 1:210 E MURTA ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1018
Practice Address - Country:US
Practice Address - Phone:573-783-2788
Practice Address - Fax:573-783-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006148332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621894401Medicaid
MO1253710001Medicare NSC