Provider Demographics
NPI:1346717097
Name:MEDLEY PHARMACY INC
Entity type:Organization
Organization Name:MEDLEY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOCAL HEALTH
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSOURI INC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-0885
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-0528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 E. HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066
Practice Address - Country:US
Practice Address - Phone:573-437-3440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601586209Medicaid