Healthcare Provider Details

I. General information

NPI: 1518980986
Provider Name (Legal Business Name): SHELL KNOB PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24832 STATE HIGHWAY 39
SHELL KNOB MO
65747-8417
US

IV. Provider business mailing address

PO BOX 419
SHELL KNOB MO
65747-0419
US

V. Phone/Fax

Practice location:
  • Phone: 417-858-2200
  • Fax: 417-858-2216
Mailing address:
  • Phone: 417-858-2200
  • Fax: 417-858-2216

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 Number2016013824
License Number StateMO

VIII. Authorized Official

Name: CONG DANG
Title or Position: OWNER
Credential:
Phone: 417-766-6990