Healthcare Provider Details

I. General information

NPI: 1053514356
Provider Name (Legal Business Name): SEMO DRUG OF KENNETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 1ST ST
KENNETT MO
63857-2526
US

IV. Provider business mailing address

1312 1ST ST
KENNETT MO
63857-2526
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-8880
  • Fax: 573-888-3889
Mailing address:
  • Phone: 573-888-8880
  • Fax: 573-888-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. TYSON WALLACE
Title or Position: PHARMACY MANAGER
Credential: PHARM.D.
Phone: 573-888-8880