Healthcare Provider Details

I. General information

NPI: 1639606320
Provider Name (Legal Business Name): CORI DYKES PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CORTNEY LN
CRANE MO
65633-9192
US

IV. Provider business mailing address

104 CORTNEY LN
CRANE MO
65633-9192
US

V. Phone/Fax

Practice location:
  • Phone: 417-723-5241
  • Fax: 417-723-5228
Mailing address:
  • Phone: 417-723-5241
  • Fax: 417-723-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2006025294
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: