Healthcare Provider Details

I. General information

NPI: 1205436946
Provider Name (Legal Business Name): DOUGLAS FAULKNER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 S 37TH ST
BETHANY MO
64424
US

IV. Provider business mailing address

810 S 37TH ST
BETHANY MO
64424
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-4430
  • Fax: 660-425-3539
Mailing address:
  • Phone: 660-425-4430
  • Fax: 660-425-3539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number041089
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: