Provider Demographics
NPI:1386706992
Name:COURT SQUARE PHARMACY, INC
Entity type:Organization
Organization Name:COURT SQUARE PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-679-2650
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:THEODOSIA
Mailing Address - State:MO
Mailing Address - Zip Code:65761-0353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 US HIGHWAY 160 STE 1
Practice Address - Street 2:
Practice Address - City:THEODOSIA
Practice Address - State:MO
Practice Address - Zip Code:65761-6539
Practice Address - Country:US
Practice Address - Phone:417-273-4555
Practice Address - Fax:417-273-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20040085183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049026OtherPK
MO606130102Medicaid