Provider Demographics
NPI:1053514356
Name:SEMO DRUG OF KENNETT
Entity type:Organization
Organization Name:SEMO DRUG OF KENNETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-888-8880
Mailing Address - Street 1:1312 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2526
Mailing Address - Country:US
Mailing Address - Phone:573-888-8880
Mailing Address - Fax:573-888-3889
Practice Address - Street 1:1312 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2526
Practice Address - Country:US
Practice Address - Phone:573-888-8880
Practice Address - Fax:573-888-3889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO858466006Medicaid