Healthcare Provider Details

I. General information

NPI: 1972304525
Provider Name (Legal Business Name): BART A ROUGHTON PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 W AUSTIN BLVD
NEVADA MO
64772-2805
US

IV. Provider business mailing address

1407 W AUSTIN BLVD
NEVADA MO
64772-2805
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-3953
  • Fax: 417-667-3953
Mailing address:
  • Phone: 417-667-3953
  • Fax: 417-667-3953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042078
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: