Healthcare Provider Details

I. General information

NPI: 1124127691
Provider Name (Legal Business Name): ZUMWALT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PUBLIC SQ
STOCKTON MO
65785-7617
US

IV. Provider business mailing address

19 PUBLIC SQ
STOCKTON MO
65785-7617
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-3128
  • Fax: 417-276-4914
Mailing address:
  • Phone: 417-276-3128
  • Fax: 417-276-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3723
License Number StateMO

VIII. Authorized Official

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