Healthcare Provider Details

I. General information

NPI: 1639165160
Provider Name (Legal Business Name): PROFESSIONAL PRESCRIPTION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 FESTUS CENTRE DR
FESTUS MO
63028-2458
US

IV. Provider business mailing address

1131 N DESLOGE DR
DESLOGE MO
63601-2936
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-2224
  • Fax: 636-933-2264
Mailing address:
  • Phone: 573-431-6677
  • Fax: 573-431-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2004029045
License Number StateMO

VIII. Authorized Official

Name: DOUGLAS RADEMAKER
Title or Position: MANAGING MEMBER
Credential: RPH
Phone: 636-933-2224