Provider Demographics
NPI:1285650135
Name:EVANS DRUGS LOCKWOOD
Entity Type:Organization
Organization Name:EVANS DRUGS LOCKWOOD
Other - Org Name:OLIVE BRANCH TRADING CO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-3313
Mailing Address - Street 1:725 MAIN ST
Mailing Address - Street 2:PO BOX R
Mailing Address - City:LOCKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65682-9803
Mailing Address - Country:US
Mailing Address - Phone:417-232-4721
Mailing Address - Fax:417-232-5099
Practice Address - Street 1:725 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCKWOOD
Practice Address - State:MO
Practice Address - Zip Code:65682-9803
Practice Address - Country:US
Practice Address - Phone:417-232-4721
Practice Address - Fax:417-232-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0050353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600118509Medicaid
2051138OtherPK
1157980001Medicare NSC