Healthcare Provider Details

I. General information

NPI: 1164616678
Provider Name (Legal Business Name): ST. JOHN'S REGIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL DR
LEBANON MO
65536-9215
US

IV. Provider business mailing address

200 HOSPITAL DR
LEBANON MO
65536-9215
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6770
  • Fax: 417-533-6777
Mailing address:
  • Phone: 417-533-6770
  • Fax: 417-533-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number006619
License Number StateMO

VIII. Authorized Official

Name: ROB SHOCKLEY
Title or Position: REATIL COORDINATOR
Credential:
Phone: 417-820-6624