Provider Demographics
NPI:1831640275
Name:KB OSCEOLA DRUG LLC
Entity Type:Organization
Organization Name:KB OSCEOLA DRUG LLC
Other - Org Name:EVANS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER,AO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-3313
Mailing Address - Street 1:675 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:MO
Mailing Address - Zip Code:64776-2934
Mailing Address - Country:US
Mailing Address - Phone:417-646-2301
Mailing Address - Fax:417-646-2456
Practice Address - Street 1:675 3RD ST
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:MO
Practice Address - Zip Code:64776-2934
Practice Address - Country:US
Practice Address - Phone:417-646-2301
Practice Address - Fax:417-646-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO20160426383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600038893Medicaid
2164581OtherPK