Healthcare Provider Details

I. General information

NPI: 1023610433
Provider Name (Legal Business Name): BRIAN ALAN CASEBOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 PARK CIRCLE DR
BROOKFIELD MO
64628-7920
US

IV. Provider business mailing address

26713 IRA DR
BROOKFIELD MO
64628-8391
US

V. Phone/Fax

Practice location:
  • Phone: 660-258-7404
  • Fax:
Mailing address:
  • Phone: 660-734-0989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number043946
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: