Healthcare Provider Details

I. General information

NPI: 1124123724
Provider Name (Legal Business Name): KREISLER DRUG #3 INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E OHIO STREET
CLINTON MO
64735-2429
US

IV. Provider business mailing address

1810 E OHIO ST
CLINTON MO
64735-2429
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-2227
  • Fax: 660-885-6589
Mailing address:
  • Phone: 660-885-2227
  • Fax: 660-885-6589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4203
License Number StateMO

VIII. Authorized Official

Name: MR. SAMUEL W. KERNOHAN
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 660-885-2227