Provider Demographics
NPI:1669513594
Name:MOBERLY PROFESSIONAL ARTS PHARMACY INC.
Entity type:Organization
Organization Name:MOBERLY PROFESSIONAL ARTS PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-263-6611
Mailing Address - Street 1:1513 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9407
Mailing Address - Country:US
Mailing Address - Phone:660-263-6611
Mailing Address - Fax:660-263-4819
Practice Address - Street 1:1513 UNION AVE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9407
Practice Address - Country:US
Practice Address - Phone:660-263-6611
Practice Address - Fax:660-263-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPS0038843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1236690001Medicare NSC