Provider Demographics
NPI:1093576951
Name:KIRK, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:KIRK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-1228
Mailing Address - Country:US
Mailing Address - Phone:417-476-2828
Mailing Address - Fax:
Practice Address - Street 1:119 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PIERCE CITY
Practice Address - State:MO
Practice Address - Zip Code:65723-1228
Practice Address - Country:US
Practice Address - Phone:417-476-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist