Healthcare Provider Details

I. General information

NPI: 1942958798
Provider Name (Legal Business Name): KELSEY LANE HOLDER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S MAIN ST
CHARLESTON MO
63834-1644
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 Number2021033955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: