Provider Demographics
NPI:1134579923
Name:KB KIRKSVILLE PHARMACY LLC
Entity type:Organization
Organization Name:KB KIRKSVILLE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/AO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:417-876-3313
Mailing Address - Street 1:1611 S BALTIMORE ST
Mailing Address - Street 2:STE B
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4518
Mailing Address - Country:US
Mailing Address - Phone:660-956-7010
Mailing Address - Fax:660-956-7015
Practice Address - Street 1:1611 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4518
Practice Address - Country:US
Practice Address - Phone:660-956-7010
Practice Address - Fax:660-956-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 333600000X
MO20160299353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160612OtherPK
MO600035560Medicaid
MO16284000042Medicaid