Provider Demographics
NPI:1902461908
Name:HEALTH CARE PHARMACY OF PERRYVILLE, LLC
Entity Type:Organization
Organization Name:HEALTH CARE PHARMACY OF PERRYVILLE, LLC
Other - Org Name:HEALTHCARE HEALTHWISE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAVANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-535-4911
Mailing Address - Street 1:628 N OLD ST MARYS RD
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775
Mailing Address - Country:US
Mailing Address - Phone:573-547-2517
Mailing Address - Fax:
Practice Address - Street 1:628 N OLD ST MARYS RD
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775
Practice Address - Country:US
Practice Address - Phone:573-547-2517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600123608Medicaid