Healthcare Provider Details

I. General information

NPI: 1164113825
Provider Name (Legal Business Name): CARLY OBRIEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 N STATE ST
IOLA KS
66749-1677
US

IV. Provider business mailing address

2051 N STATE ST
IOLA KS
66749-1677
US

V. Phone/Fax

Practice location:
  • Phone: 620-380-6400
  • Fax: 620-380-6602
Mailing address:
  • Phone: 620-380-6400
  • Fax: 620-380-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-109369
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: