Healthcare Provider Details

I. General information

NPI: 1649391020
Provider Name (Legal Business Name): BOURBON DRUGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 E PINE ST
BOURBON MO
65441-7506
US

IV. Provider business mailing address

PO BOX 70
BOURBON MO
65441-0070
US

V. Phone/Fax

Practice location:
  • Phone: 573-732-4921
  • Fax: 573-732-3640
Mailing address:
  • Phone: 573-732-4921
  • Fax: 573-732-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number005285
License Number StateMO

VIII. Authorized Official

Name: THOMAS BURNETT
Title or Position: PIC
Credential: RPH
Phone: 573-732-4921