Healthcare Provider Details

I. General information

NPI: 1316953987
Provider Name (Legal Business Name): OSAGE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513B N GRAND AVE
DONIPHAN MO
63935-1405
US

IV. Provider business mailing address

2029 MEADOWS RD
POPLAR BLUFF MO
63901-2723
US

V. Phone/Fax

Practice location:
  • Phone: 573-996-3784
  • Fax: 573-996-5275
Mailing address:
  • Phone: 573-686-6211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK KLEINBECK
Title or Position: PRESIDENT
Credential:
Phone: 573-686-6211