Healthcare Provider Details

I. General information

NPI: 1013605997
Provider Name (Legal Business Name): DEJACE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BROADWAY ST STE A
ELSBERRY MO
63343-1345
US

IV. Provider business mailing address

106 BROADWAY ST STE A
ELSBERRY MO
63343-1345
US

V. Phone/Fax

Practice location:
  • Phone: 573-898-2550
  • Fax: 573-898-5730
Mailing address:
  • Phone: 573-898-2550
  • Fax: 573-898-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW OSTERKAMP
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 573-898-2550