Provider Demographics
NPI:1366545592
Name:AUSTIN PLAZA PHARMACY INC
Entity type:Organization
Organization Name:AUSTIN PLAZA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-768-1529
Mailing Address - Street 1:410 E HIGH ST STE A
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1927
Mailing Address - Country:US
Mailing Address - Phone:573-438-2349
Mailing Address - Fax:573-438-8877
Practice Address - Street 1:410 E HIGH ST STE A
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1927
Practice Address - Country:US
Practice Address - Phone:573-438-2349
Practice Address - Fax:573-438-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0027903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049323OtherPK
MO600095905Medicaid