Organization
OLD TOWN PHARMACY LLC
Active
Other names
Old Town Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SHANE MICHAEL BECKER PHARMD RPH (OWNER/MANAGER/PIC)
(417) 635-1100
Entity
Organization
Contact information
Practice address
100A CHAPEL DRIVE, MONETT, MO 65708
(417) 635-1100
(417) 635-1103
Mailing address
100A CHAPEL DR, MONETT, MO 65708
(417) 635-1100
(417) 635-1103
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
2007022497
MO
3336C0003X
Community/Retail Pharmacy
Primary
2014010847
MO
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
19735928
—
MO
01
—
2007022497
PHARMACY LIC
MO
01
—
2637506
NCPDP
—
Enumeration date
08/05/2007
Last updated
06/04/2024
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