Healthcare Provider Details

I. General information

NPI: 1598047409
Provider Name (Legal Business Name): KEVIN EUGENE BRUCE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SUGAR CREEK
FENTON MO
63026
US

IV. Provider business mailing address

11 WORTHY CT
FENTON MO
63026
US

V. Phone/Fax

Practice location:
  • Phone: 636-326-5113
  • Fax:
Mailing address:
  • Phone: 636-225-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number041565
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: