Provider Demographics
NPI:1649391020
Name:BOURBON DRUGS INC
Entity Type:Organization
Organization Name:BOURBON DRUGS INC
Other - Org Name:BOURBON DRUGS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-732-4921
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:BOURBON
Mailing Address - State:MO
Mailing Address - Zip Code:65441-0070
Mailing Address - Country:US
Mailing Address - Phone:573-732-4921
Mailing Address - Fax:573-732-3640
Practice Address - Street 1:386 E PINE ST
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:MO
Practice Address - Zip Code:65441-7506
Practice Address - Country:US
Practice Address - Phone:573-732-4921
Practice Address - Fax:573-732-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0052853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600247431Medicaid
2614926OtherNCPDP PROVIDER IDENTIFICATION NUMBER