Provider Demographics
NPI:1992718878
Name:DAUGHERTY PHARMACIES, LLC
Entity type:Organization
Organization Name:DAUGHERTY PHARMACIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-468-2530
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-0093
Mailing Address - Country:US
Mailing Address - Phone:417-468-2530
Mailing Address - Fax:417-859-7116
Practice Address - Street 1:1365 SPUR DR
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2311
Practice Address - Country:US
Practice Address - Phone:417-468-2530
Practice Address - Fax:417-859-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620663401Medicaid