Healthcare Provider Details

I. General information

NPI: 1740012004
Provider Name (Legal Business Name): JOELLEN AVILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S US HIGHWAY 169
GOWER MO
64454-9116
US

IV. Provider business mailing address

315 S US HIGHWAY 169
GOWER MO
64454-9116
US

V. Phone/Fax

Practice location:
  • Phone: 816-385-5995
  • Fax:
Mailing address:
  • Phone: 816-385-5995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045151
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: