Healthcare Provider Details

I. General information

NPI: 1346391026
Provider Name (Legal Business Name): ROGER A. BALES PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E ROSS ST
CLEARWATER KS
67026
US

IV. Provider business mailing address

6657 ONEIL CT
WICHITA KS
67212-6326
US

V. Phone/Fax

Practice location:
  • Phone: 620-584-2025
  • Fax:
Mailing address:
  • Phone: 316-943-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-08926
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: