Provider Demographics
NPI:1477659779
Name:ADRIAN KREISLER DRUG INC.
Entity Type:Organization
Organization Name:ADRIAN KREISLER DRUG INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STORE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-297-8833
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720
Mailing Address - Country:US
Mailing Address - Phone:816-297-8833
Mailing Address - Fax:816-297-2900
Practice Address - Street 1:21 E MAIN ST.
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MO
Practice Address - Zip Code:64720
Practice Address - Country:US
Practice Address - Phone:816-297-8833
Practice Address - Fax:816-297-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
MO59773336C0003X
MO0059773336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO608271102Medicaid
MO1194360001Medicare NSC