Healthcare Provider Details

I. General information

NPI: 1619561354
Provider Name (Legal Business Name): KELLIE L COOK R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 VREELAND RD
HILLSBORO MO
63050-5091
US

IV. Provider business mailing address

739 GODDARD AVE
CHESTERFIELD MO
63005-1106
US

V. Phone/Fax

Practice location:
  • Phone: 636-208-2878
  • Fax:
Mailing address:
  • Phone: 636-534-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number043732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: