Provider Demographics
NPI:1518980986
Name:SHELL KNOB PHARMACY LLC
Entity Type:Organization
Organization Name:SHELL KNOB PHARMACY LLC
Other - Org Name:PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONG
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-766-6990
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:SHELL KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:65747-0419
Mailing Address - Country:US
Mailing Address - Phone:417-858-2200
Mailing Address - Fax:417-858-2216
Practice Address - Street 1:24832 STATE HIGHWAY 39
Practice Address - Street 2:
Practice Address - City:SHELL KNOB
Practice Address - State:MO
Practice Address - Zip Code:65747-8417
Practice Address - Country:US
Practice Address - Phone:417-858-2200
Practice Address - Fax:417-858-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20160138243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602912701Medicaid
2159951OtherPK