Provider Demographics
NPI:1588714802
Name:DR MAMAE, INC.
Entity type:Organization
Organization Name:DR MAMAE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANEL
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:660-947-2484
Mailing Address - Street 1:121 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63565-1624
Mailing Address - Country:US
Mailing Address - Phone:660-947-2480
Mailing Address - Fax:660-947-7912
Practice Address - Street 1:121 S 16TH ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:MO
Practice Address - Zip Code:63565-1624
Practice Address - Country:US
Practice Address - Phone:660-947-2480
Practice Address - Fax:660-947-7912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20030005433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601347917Medicaid
2051475OtherPK
IA0561860Medicaid
MO621347905Medicaid
MO601347917Medicaid