Healthcare Provider Details

I. General information

NPI: 1811375462
Provider Name (Legal Business Name): KRISTIN MEBRUER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 SOUTHWEST BLVD
JEFFERSON CITY MO
65109-2468
US

IV. Provider business mailing address

3526 AMAZONAS DR
JEFFERSON CITY MO
65109-5716
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-2021
  • Fax:
Mailing address:
  • Phone: 573-659-0650
  • Fax: 573-659-0651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2012028243
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: