Provider Demographics
NPI:1285774828
Name:OSAGE PHARMACY, LLC
Entity type:Organization
Organization Name:OSAGE PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KLEINBECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-778-6804
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-4556
Mailing Address - Fax:573-686-4529
Practice Address - Street 1:513B GRAND AVE
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1405
Practice Address - Country:US
Practice Address - Phone:573-996-3784
Practice Address - Fax:573-996-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO623809308332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2637051OtherNCPDP
MO603809302Medicaid
MOBM98593489OtherDEA