Healthcare Provider Details

I. General information

NPI: 1679609721
Provider Name (Legal Business Name): KEVIN ALAN MCCULLOUGH PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E US HIGHWAY 54
EL DORADO SPRINGS MO
64744-1925
US

IV. Provider business mailing address

209 E US HIGHWAY 54
EL DORADO SPRINGS MO
64744-1925
US

V. Phone/Fax

Practice location:
  • Phone: 417-876-3313
  • Fax: 417-876-3813
Mailing address:
  • Phone: 417-876-3313
  • Fax: 417-876-3813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2005000317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: