Provider Demographics
NPI:1578371621
Name:MISSOURI DELTA MEDICAL CENTER
Entity type:Organization
Organization Name:MISSOURI DELTA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:SANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-472-7423
Mailing Address - Street 1:412 W BROADWATER RD
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1358
Mailing Address - Country:US
Mailing Address - Phone:573-901-5001
Mailing Address - Fax:573-990-1284
Practice Address - Street 1:412 W BROADWATER RD
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1358
Practice Address - Country:US
Practice Address - Phone:573-901-5001
Practice Address - Fax:800-617-8692
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOURI DELTA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy