MEDICARE: KOERBLES PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	005962	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2126855	OTHER		PK

General Provider Information

NPI Number	:	1740246636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOERBLES PHARMACY INC

Provider Business Mailing Address
First Line	:	3650 E SUNSHINE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65809-2820
Country	:	US
Telephone Number	:	417-889-7898
Fax Number	:	417-889-0018

Provider Business Practice Location Address
First Line	:	3650 E SUNSHINE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65809-2820
Country	:	US
Telephone Number	:	417-889-7898
Fax Number	:	417-889-0018

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JIM MONTGOMERY
Credential	:
Telephone Number	:	417-889-7898

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	11/06/2013

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