Healthcare Provider Details

I. General information

NPI: 1134579923
Provider Name (Legal Business Name): KB KIRKSVILLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 S BALTIMORE ST
KIRKSVILLE MO
63501-4518
US

IV. Provider business mailing address

1611 S BALTIMORE ST STE B
KIRKSVILLE MO
63501-4518
US

V. Phone/Fax

Practice location:
  • Phone: 660-956-7010
  • Fax: 660-956-7015
Mailing address:
  • Phone: 660-956-7010
  • Fax: 660-956-7015

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 Number2016029935
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TRACY TIMMERMANN
Title or Position: MANAGER/AO
Credential: RPH
Phone: 417-876-3313