Provider Demographics
NPI:1144701079
Name:SUMMERS PHARMACY OF WARRENSBURG, LLC
Entity type:Organization
Organization Name:SUMMERS PHARMACY OF WARRENSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:660-885-3034
Mailing Address - Street 1:605 PAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-2757
Mailing Address - Country:US
Mailing Address - Phone:660-383-1910
Mailing Address - Fax:660-885-5888
Practice Address - Street 1:611 BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093
Practice Address - Country:US
Practice Address - Phone:660-429-0559
Practice Address - Fax:660-530-6161
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMERS PHARMACY ENTERPRISES, CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-28
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018030729333600000X
3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600059693Medicaid