Provider Demographics
NPI:1831294792
Name:BUFFALO PROFESSIONAL PHARMACY INC
Entity Type:Organization
Organization Name:BUFFALO PROFESSIONAL PHARMACY INC
Other - Org Name:CORNER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CHIEF RPH
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-345-6500
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-0710
Mailing Address - Country:US
Mailing Address - Phone:417-345-6500
Mailing Address - Fax:417-345-6565
Practice Address - Street 1:308 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-7635
Practice Address - Country:US
Practice Address - Phone:417-345-6500
Practice Address - Fax:417-345-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0052403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602895104Medicaid
2051305OtherPK