Healthcare Provider Details

I. General information

NPI: 1376039149
Provider Name (Legal Business Name): CARDINAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 TRIAD CTR W # 108
O FALLON MO
63366-7541
US

IV. Provider business mailing address

108 TRIAD CTR W # 108
O FALLON MO
63366-7541
US

V. Phone/Fax

Practice location:
  • Phone: 833-347-4217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2018021047
License Number StateMO

VIII. Authorized Official

Name: MICHAEL PETERS
Title or Position: OWNER
Credential:
Phone: 702-245-7307