Healthcare Provider Details

I. General information

NPI: 1285650135
Provider Name (Legal Business Name): EVANS DRUGS LOCKWOOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 MAIN ST
LOCKWOOD MO
65682-9803
US

IV. Provider business mailing address

725 MAIN ST PO BOX R
LOCKWOOD MO
65682-9803
US

V. Phone/Fax

Practice location:
  • Phone: 417-232-4721
  • Fax: 417-232-5099
Mailing address:
  • Phone: 417-232-4721
  • Fax: 417-232-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number005035
License Number StateMO

VIII. Authorized Official

Name: KEVIN ALAN MCCULLOUGH
Title or Position: OWNER
Credential:
Phone: 417-876-3313