Provider Demographics
NPI:1063513398
Name:CARTHAGE PHARMACY SERVICES INC
Entity type:Organization
Organization Name:CARTHAGE PHARMACY SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVIN
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-461-7777
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-0068
Mailing Address - Country:US
Mailing Address - Phone:417-466-2000
Mailing Address - Fax:417-466-2028
Practice Address - Street 1:606 E MOUNT VERNON BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-9100
Practice Address - Country:US
Practice Address - Phone:417-466-2000
Practice Address - Fax:417-466-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011847333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601917503Medicaid
MO601917503Medicaid