Healthcare Provider Details

I. General information

NPI: 1114448404
Provider Name (Legal Business Name): MYERS FAMILY CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 CEDAR ST
CEDAR VALE KS
67024-9704
US

IV. Provider business mailing address

616 CEDAR ST
CEDAR VALE KS
67024-9704
US

V. Phone/Fax

Practice location:
  • Phone: 620-758-2711
  • Fax:
Mailing address:
  • Phone: 620-758-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number21103265
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2-103331
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-103265
License Number StateKS

VIII. Authorized Official

Name: DR. DOUG BAGGETT
Title or Position: MANAGER
Credential: DPH
Phone: 620-758-2711