Provider Demographics
NPI:1194897983
Name:SIKESTON PHARMACY LLC
Entity type:Organization
Organization Name:SIKESTON PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHREIBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-965-4700
Mailing Address - Street 1:507 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-2105
Mailing Address - Country:US
Mailing Address - Phone:573-471-4401
Mailing Address - Fax:573-471-5448
Practice Address - Street 1:507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-2105
Practice Address - Country:US
Practice Address - Phone:573-471-4401
Practice Address - Fax:573-471-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 320900000X, 3336C0003X
MO20150199883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152744OtherPK
MO603536608Medicaid
MO623536604Medicaid
MO0461830001Medicare NSC
MOBM4252728OtherDEA #