Provider Demographics
NPI:1124127691
Name:ZUMWALT PHARMACY INC
Entity type:Organization
Organization Name:ZUMWALT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-876-3313
Mailing Address - Street 1:19 PUBLIC SQ
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:MO
Mailing Address - Zip Code:65785-7617
Mailing Address - Country:US
Mailing Address - Phone:417-276-3128
Mailing Address - Fax:417-276-4914
Practice Address - Street 1:19 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:MO
Practice Address - Zip Code:65785-7617
Practice Address - Country:US
Practice Address - Phone:417-276-3128
Practice Address - Fax:417-276-4914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 332B00000X, 333600000X
MO37233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600900005Medicaid
2049877OtherPK
1239530001Medicare NSC