Organization
SEMO DRUG OF KENNETT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TYSON WALLACE PHARM.D. (PHARMACY MANAGER)
(573) 888-8880
Entity
Organization
Contact information
Practice address
1312 1ST ST, KENNETT, MO 63857-2526
(573) 888-8880
(573) 888-3889
Mailing address
1312 1ST ST, KENNETT, MO 63857-2526
(573) 888-8880
(573) 888-3889
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
858466006
—
MO
Enumeration date
06/06/2007
Last updated
08/22/2020
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