Provider Demographics
NPI:1578679056
Name:KB EVANS DRUG INC
Entity Type:Organization
Organization Name:KB EVANS DRUG INC
Other - Org Name:EVANS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
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:417-876-3813
Practice Address - Street 1:209 E US HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-1925
Practice Address - Country:US
Practice Address - Phone:417-876-3313
Practice Address - Fax:417-876-3813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20100426803336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620120501Medicaid
MO600120505Medicaid
2128300OtherPK
000015355Medicare PIN
MO600120505Medicaid