Healthcare Provider Details

I. General information

NPI: 1326648155
Provider Name (Legal Business Name): KAYLA REVERMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W US HIGHWAY 50 PHARMACY
O FALLON IL
62269
US

IV. Provider business mailing address

1350 W US HIGHWAY 50 PHARMACY
O FALLON IL
62269
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-0507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2016011547
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051298647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: