Healthcare Provider Details

I. General information

NPI: 1831640275
Provider Name (Legal Business Name): KB OSCEOLA DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 04/11/2020
Certification Date: 04/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 3RD ST
OSCEOLA MO
64776-2934
US

IV. Provider business mailing address

675 3RD ST
OSCEOLA MO
64776-2934
US

V. Phone/Fax

Practice location:
  • Phone: 417-646-2301
  • Fax: 417-646-2456
Mailing address:
  • Phone: 417-646-2301
  • Fax: 417-646-2456

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 Number2016042638
License Number StateMO

VIII. Authorized Official

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