Provider Demographics
NPI:1902974140
Name:NORTHWEST PHARMACY INC
Entity type:Organization
Organization Name:NORTHWEST PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEINBECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-686-6211
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-6211
Mailing Address - Fax:573-686-2219
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-6211
Practice Address - Fax:573-686-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20040199983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2627492OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO600059729Medicaid
MO600059729Medicaid