Healthcare Provider Details

I. General information

NPI: 1376068114
Provider Name (Legal Business Name): DR. BIANCA DAISY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S. MAIN STREET
CHARLESTON MO
63834
US

IV. Provider business mailing address

406 S MAIN ST
CHARLESTON MO
63834-1644
US

V. Phone/Fax

Practice location:
  • Phone: 573-683-3307
  • Fax:
Mailing address:
  • Phone: 573-683-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2017028019
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: