Healthcare Provider Details

I. General information

NPI: 1861476426
Provider Name (Legal Business Name): ELLEYS PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 S HUDSON ST
BUCKNER MO
64016-8142
US

IV. Provider business mailing address

306 S HUDSON ST
BUCKNER MO
64016-8142
US

V. Phone/Fax

Practice location:
  • Phone: 816-650-5611
  • Fax: 816-650-5611
Mailing address:
  • Phone: 816-650-5611
  • Fax: 816-650-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number027748
License Number StateMO

VIII. Authorized Official

Name: MR. WILLIAM RUSSELL ELLEY
Title or Position: RPH/OWNER
Credential: RPH
Phone: 816-650-5611