NPIMap

Organization Active NPI

Prescription Drug Store LLC

  • Community/Retail Pharmacy
  • Caruthersville, MO
National Provider Identifier
1497790968
Registry record updated Jan 28, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
000915 Issued in MO
Legal business name
PRESCRIPTION DRUG STORE LLC
Practice address
410 Ward Ave
Caruthersville, MO 63830
Phone
(573) 333-4890
Fax
(573) 333-0306
NPI assigned
Jun 18, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 28, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Shane Alan Dudley, RPH
Title
Owner / Pharmacist
Phone
(573) 333-4890

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 000915 MO Primary
Long Term Care Pharmacy 3336L0003X

Addresses

Primary practice location

410 Ward Ave
Caruthersville, MO 63830

Mailing address

410 Ward Ave
Caruthersville, MO 63830
Phone (573) 333-4890

Other identifiers 1

IdentifierTypeStateIssuer
600126106MedicaidMO

National Provider Directory

National Provider Directory
Tax ID family
Prescription Drug Store3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Subparts reporting this organization as parent 2

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643328000000",
    "number": "1497790968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "410 WARD AVE",
            "city": "CARUTHERSVILLE",
            "state": "MO",
            "postal_code": "63830",
            "telephone_number": "573-333-4890",
            "fax_number": "573-333-0306"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 WARD AVE",
            "city": "CARUTHERSVILLE",
            "state": "MO",
            "postal_code": "63830",
            "telephone_number": "573-333-4890",
            "fax_number": "573-333-0306"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRESCRIPTION DRUG STORE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-18",
        "last_updated": "2022-01-28",
        "certification_date": "2022-01-28",
        "status": "A",
        "authorized_official_last_name": "DUDLEY",
        "authorized_official_first_name": "SHANE",
        "authorized_official_middle_name": "ALAN",
        "authorized_official_title_or_position": "OWNER / PHARMACIST",
        "authorized_official_telephone_number": "573-333-4890",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MO",
            "license": "000915",
            "primary": true
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "600126106",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Caruthersville, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.