Healthcare Provider Details

I. General information

NPI: 1528169083
Provider Name (Legal Business Name): HERMITAGE PROFESSIONAL ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/19/2025
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23649 DALLAS ST
HERMITAGE MO
65668-9231
US

IV. Provider business mailing address

PO BOX 370
HERMITAGE MO
65668
US

V. Phone/Fax

Practice location:
  • Phone: 417-745-2136
  • Fax: 417-745-2130
Mailing address:
  • Phone: 417-745-2136
  • Fax: 417-745-2130

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 Number004831
License Number StateMO

VIII. Authorized Official

Name: AL NYBERG
Title or Position: PRESIDENT
Credential:
Phone: 417-745-2136