Provider Demographics
NPI:1265421663
Name:KNL PRESCRIPTIONS LLC
Entity type:Organization
Organization Name:KNL PRESCRIPTIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:573-335-8207
Mailing Address - Street 1:37 DOCTORS PARK # 7
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4956
Mailing Address - Country:US
Mailing Address - Phone:573-803-2040
Mailing Address - Fax:573-335-4904
Practice Address - Street 1:710 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5514
Practice Address - Country:US
Practice Address - Phone:573-335-8207
Practice Address - Fax:573-335-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
MO20110122803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130422OtherPK
MO600200208Medicaid
2130422OtherPK
6188910001Medicare NSC