Provider Demographics
NPI:1821083312
Name:KCJSE INC
Entity Type:Organization
Organization Name:KCJSE INC
Other - Org Name:THE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JS
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:816-632-7211
Mailing Address - Street 1:610 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-1831
Mailing Address - Country:US
Mailing Address - Phone:816-632-7211
Mailing Address - Fax:816-632-3645
Practice Address - Street 1:610 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-1831
Practice Address - Country:US
Practice Address - Phone:816-632-7211
Practice Address - Fax:816-632-3645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0044933336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600280101Medicaid
MO620028100Medicaid
2049743OtherPK
MO0205130001Medicare PIN