MEDICARE: CARISSA VIRTUE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2012021905	MO

General Provider Information

NPI Number	:	1396161618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA VIRTUE

Provider Business Mailing Address
First Line	:	1206 W ROBIN ST
Second Line	:
City	:	OZARK
State	:	MO
Zip	:	65721-8091
Country	:	US
Telephone Number	:	417-619-3640
Fax Number	:

Provider Business Practice Location Address
First Line	:	604A E SOUTH ST
Second Line	:
City	:	OZARK
State	:	MO
Zip	:	65721-8912
Country	:	US
Telephone Number	:	417-581-7777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	03/11/2014

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Directions to “ CARISSA VIRTUE ” Practice Location

Language	Start Address	Practice Location

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