Healthcare Provider Details

I. General information

NPI: 1083834998
Provider Name (Legal Business Name): MT OREAD PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 CLINTON PARKWAY PLACE SUITE 220
LAWRENCE KS
66047-2195
US

IV. Provider business mailing address

3510 CLINTON PARKWAY PLACE SUITE 220
LAWRENCE KS
66047-2195
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-0111
  • Fax: 785-843-3818
Mailing address:
  • Phone: 785-843-0111
  • Fax: 785-843-3818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number08834
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ERICK W AXCELL
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 785-843-0111