Healthcare Provider Details

I. General information

NPI: 1568202356
Provider Name (Legal Business Name): OZARK MOUNTAIN COMPOUNDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 COLLINS AVE
AVA MO
65608-5532
US

IV. Provider business mailing address

806 COLLINS AVE
AVA MO
65608-5532
US

V. Phone/Fax

Practice location:
  • Phone: 228-222-7169
  • Fax:
Mailing address:
  • Phone: 228-222-7169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: VANESSA LOFTIS
Title or Position: OWNER
Credential: NP
Phone: 417-543-4631