Provider Demographics
NPI:1033255179
Name:KINKEAD PHARMACY, INC.
Entity Type:Organization
Organization Name:KINKEAD PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINKEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-682-2155
Mailing Address - Street 1:105 S ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1303
Mailing Address - Country:US
Mailing Address - Phone:573-682-2155
Mailing Address - Fax:
Practice Address - Street 1:105 S ALLEN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1303
Practice Address - Country:US
Practice Address - Phone:573-682-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0418453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600050702Medicaid
MO2605446Medicare UPIN