Provider Demographics
NPI:1366878837
Name:MITCHELL DRUG OF MALDEN LLC
Entity type:Organization
Organization Name:MITCHELL DRUG OF MALDEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HARLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-281-2299
Mailing Address - Street 1:1128 N DOUGLASS ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1342
Mailing Address - Country:US
Mailing Address - Phone:573-281-2299
Mailing Address - Fax:573-281-3391
Practice Address - Street 1:1128 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1342
Practice Address - Country:US
Practice Address - Phone:573-281-2299
Practice Address - Fax:573-281-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130339563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142079OtherPK