=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245364066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 BARRON RD
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-686-6211
-----------------------------------------------------
Fax | 573-686-2219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2210 BARRON RD
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-686-6211
-----------------------------------------------------
Fax | 573-686-2219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARK T KLEINBECK
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 573-686-6211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 620059725
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------