Healthcare Provider Details

I. General information

NPI: 1487130449
Provider Name (Legal Business Name): KENDRICK DEAN GREATHOUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9074 OVERLAND PLZ
OVERLAND MO
63114-6122
US

IV. Provider business mailing address

9074 OVERLAND PLZ
OVERLAND MO
63114-6122
US

V. Phone/Fax

Practice location:
  • Phone: 314-426-4211
  • Fax: 314-426-4806
Mailing address:
  • Phone: 314-426-4211
  • Fax: 314-426-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015024606
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: