Healthcare Provider Details

I. General information

NPI: 1154427516
Provider Name (Legal Business Name): KREISLER CLNIC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N. SECOND ST.
CLINTON MO
64735
US

IV. Provider business mailing address

PO BOX 528
CLINTON MO
64735
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-4646
  • Fax:
Mailing address:
  • Phone: 660-885-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number5423
License Number StateMO

VIII. Authorized Official

Name: MARY D. KLINE-RADFORD
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 660-885-4646