Provider Demographics
NPI:1043309263
Name:BORING REXALL DRUG
Entity Type:Organization
Organization Name:BORING REXALL DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMAIST
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-438-5162
Mailing Address - Street 1:161 W MAIN
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355
Mailing Address - Country:US
Mailing Address - Phone:660-438-5162
Mailing Address - Fax:660-438-5083
Practice Address - Street 1:161 W MAIN
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355
Practice Address - Country:US
Practice Address - Phone:660-438-5162
Practice Address - Fax:660-438-5083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040065063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6000988000Medicaid