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General NPI Number Information
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NPI Number | 1053514356
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Entity Type | Organization
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Legal Business Name | SEMO DRUG OF KENNETT
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1312 1ST ST
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City | KENNETT
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State | MO
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Zip | 63857-2526
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Country | US
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Telephone | 573-888-8880
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Fax | 573-888-3889
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Provider Business Mailing Address
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Address Line | 1312 1ST ST
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City | KENNETT
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State | MO
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Zip | 63857-2526
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Country | US
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Telephone | 573-888-8880
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Fax | 573-888-3889
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | DR. TYSON WALLACE
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Credential | PHARM.D.
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Telephone | 573-888-8880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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