Healthcare Provider Details

I. General information

NPI: 1396487823
Provider Name (Legal Business Name): KRISTY ROTH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W YOAKUM AVE
CHAFFEE MO
63740-1138
US

IV. Provider business mailing address

211 W YOAKUM AVE
CHAFFEE MO
63740-1138
US

V. Phone/Fax

Practice location:
  • Phone: 573-887-3622
  • Fax: 573-887-3309
Mailing address:
  • Phone: 573-887-3622
  • Fax: 573-887-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019027652
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: