Provider Demographics
NPI:1316043490
Name:KIMBERLING CITY PHARMACY, INC.
Entity Type:Organization
Organization Name:KIMBERLING CITY PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:417-739-2273
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:41 KIMBERLING CITY CENTER LANE
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-0908
Mailing Address - Country:US
Mailing Address - Phone:417-739-2273
Mailing Address - Fax:417-739-1706
Practice Address - Street 1:41 KIMBERLING CITY CENTER LANE
Practice Address - Street 2:
Practice Address - City:KIMBERLING CITY
Practice Address - State:MO
Practice Address - Zip Code:65686-0908
Practice Address - Country:US
Practice Address - Phone:417-739-2273
Practice Address - Fax:417-739-1706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOKI602214603Medicaid
MO2622923OtherNABP