Healthcare Provider Details

I. General information

NPI: 1184246258
Provider Name (Legal Business Name): CHASE WHITESIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GRAVES ST
CHILLICOTHEE MO
64601-3071
US

IV. Provider business mailing address

218 GREY RIDGE RD
HALE MO
64643-7206
US

V. Phone/Fax

Practice location:
  • Phone: 660-646-6550
  • Fax:
Mailing address:
  • Phone: 660-247-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015027181
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: