Healthcare Provider Details

I. General information

NPI: 1033255179
Provider Name (Legal Business Name): KINKEAD PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S ALLEN ST
CENTRALIA MO
65240-1303
US

IV. Provider business mailing address

105 S ALLEN ST
CENTRALIA MO
65240-1303
US

V. Phone/Fax

Practice location:
  • Phone: 573-682-2155
  • Fax:
Mailing address:
  • Phone: 573-682-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number041845
License Number StateMO

VIII. Authorized Official

Name: WENDY S KINKEAD
Title or Position: PRES
Credential:
Phone: 573-682-2155