Healthcare Provider Details

I. General information

NPI: 1730562968
Provider Name (Legal Business Name): MISSOURI VALLEY RESPIRATORY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E ANN ST
MALTA BEND MO
65339-1016
US

IV. Provider business mailing address

107 E ANN ST
MALTA BEND MO
65339-1016
US

V. Phone/Fax

Practice location:
  • Phone: 660-595-2142
  • Fax:
Mailing address:
  • Phone: 660-595-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2015018905
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BILL CAVINESS
Title or Position: RPH
Credential:
Phone: 660-595-2142