Provider Demographics
NPI:1346602117
Name:EVANS DRUGS SEDALIA WEST LLC
Entity Type:Organization
Organization Name:EVANS DRUGS SEDALIA WEST LLC
Other - Org Name:WOODS PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-3313
Mailing Address - Street 1:209 E US HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744-1925
Mailing Address - Country:US
Mailing Address - Phone:417-876-3313
Mailing Address - Fax:417-876-2326
Practice Address - Street 1:1400 S LIMIT AVE STE 3
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5119
Practice Address - Country:US
Practice Address - Phone:417-326-7603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606033224Medicaid
MO2022044240OtherPHARMACY LICENSE