Healthcare Provider Details

I. General information

NPI: 1972293041
Provider Name (Legal Business Name): JUSTIN TABER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 NW VICTORIA DR STE B
LEES SUMMIT MO
64086-4709
US

IV. Provider business mailing address

940 NW PRYOR RD APT 207
LEES SUMMIT MO
64081-1145
US

V. Phone/Fax

Practice location:
  • Phone: 855-937-7273
  • Fax:
Mailing address:
  • Phone: 816-507-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2021050249
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70344
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23686
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23985
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: