Healthcare Provider Details

I. General information

NPI: 1609887116
Provider Name (Legal Business Name): SAULTS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 COURT ST
FULTON MO
65251-1901
US

IV. Provider business mailing address

505 COURT ST
FULTON MO
65251-1901
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-4186
  • Fax: 573-642-8324
Mailing address:
  • Phone: 573-642-4186
  • Fax: 573-642-8324

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 Number004787
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ALTON REAL
Title or Position: OWNER,RPH,AO
Credential: RPH
Phone: 573-642-4186