Provider Demographics
NPI:1144560319
Name:MIKE STUART ENTERPRISES, INC.
Entity type:Organization
Organization Name:MIKE STUART ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-272-8064
Mailing Address - Street 1:18565 BUSINESS 13
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737-9659
Mailing Address - Country:US
Mailing Address - Phone:417-272-8064
Mailing Address - Fax:417-272-0073
Practice Address - Street 1:110 BEAR DR STE 4
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-7103
Practice Address - Country:US
Practice Address - Phone:417-469-9009
Practice Address - Fax:417-469-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013004561332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600005149Medicaid
2640921OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO600005149Medicaid