Healthcare Provider Details

I. General information

NPI: 1669200275
Provider Name (Legal Business Name): MARINA KUCHUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOSPITAL DR
COLUMBIA MO
65201-5275
US

IV. Provider business mailing address

4503 CRYSTAL ROCK CT
COLUMBIA MO
65203-8565
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2024029133
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: