Healthcare Provider Details

I. General information

NPI: 1962914234
Provider Name (Legal Business Name): KSC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 HIGHWAY 52 BYP W
LAFAYETTE TN
37083-1614
US

IV. Provider business mailing address

526 HIGHWAY 52 BYP W
LAFAYETTE TN
37083-1614
US

V. Phone/Fax

Practice location:
  • Phone: 615-666-4444
  • Fax: 615-666-2222
Mailing address:
  • Phone: 615-666-4444
  • Fax: 615-666-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY B STOVALL
Title or Position: PRESIDENT
Credential: RPH
Phone: 270-622-8888