Provider Demographics
NPI:1396291837
Name:LEGACY DRUGSTORE LLC
Entity type:Organization
Organization Name:LEGACY DRUGSTORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAUMENZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:618-267-0574
Mailing Address - Street 1:13000 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WRIGHT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63390-1041
Mailing Address - Country:US
Mailing Address - Phone:636-791-1274
Mailing Address - Fax:636-791-1326
Practice Address - Street 1:13000 VETERANS MEMORIAL PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:WRIGHT CITY
Practice Address - State:MO
Practice Address - Zip Code:63390-1041
Practice Address - Country:US
Practice Address - Phone:636-791-1274
Practice Address - Fax:636-791-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20160408673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600037942Medicaid
2163841OtherPK