Provider Demographics
NPI:1104915891
Name:ROBERT PRITCHARD
Entity type:Organization
Organization Name:ROBERT PRITCHARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRITCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-334-4432
Mailing Address - Street 1:37 DOCTORS PARK
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4956
Mailing Address - Country:US
Mailing Address - Phone:573-334-4432
Mailing Address - Fax:573-334-7290
Practice Address - Street 1:37 DOCTORS PARK
Practice Address - Street 2:SUITE 2
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4956
Practice Address - Country:US
Practice Address - Phone:573-334-4432
Practice Address - Fax:573-334-7290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0045003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602201501Medicaid
2050673OtherPK
MO602201501Medicaid