Provider Demographics
NPI:1184764573
Name:N E MO CLOSED DOOR PHARMACY L L C
Entity type:Organization
Organization Name:N E MO CLOSED DOOR PHARMACY L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:660-699-2432
Mailing Address - Street 1:214B N GRAND ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:MO
Mailing Address - Zip Code:63437-1604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214B N GRAND ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:MO
Practice Address - Zip Code:63437-1604
Practice Address - Country:US
Practice Address - Phone:660-699-2432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070011343336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626317705Medicaid
MO626317705Medicaid