Organization
IVNA MEDICAL GROUP LLC
Active
Other names
Stadium Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
VIKRANTH ANNEBOINA (MEMBER)
(816) 356-4600
Entity
Organization
Contact information
Practice address
4811 S ARROWHEAD DR, INDEPENDENCE, MO 64055-6981
(816) 356-4600
(816) 353-7296
Mailing address
4811 S ARROWHEAD DR, INDEPENDENCE, MO 64055-6981
(816) 356-4600
(816) 353-7296
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
2016039188
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2166225
PK
—
05
—
605454206
—
MO
Enumeration date
01/23/2007
Last updated
04/28/2017
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