Provider Demographics
NPI:1407887086
Name:EVANS DRUGS BOLIVAR LLC
Entity Type:Organization
Organization Name:EVANS DRUGS BOLIVAR LLC
Other - Org Name:EVANS DRUGS BOLIVAR
Other - Org Type:Doing Business As
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:417-326-5208
Mailing Address - Fax:417-876-2326
Practice Address - Street 1:703 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2630
Practice Address - Country:US
Practice Address - Phone:417-326-5208
Practice Address - Fax:417-777-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20030058213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048894OtherPK
MO606032803Medicaid
MO606032803Medicaid
MO606032902Medicaid