Healthcare Provider Details

I. General information

NPI: 1003952615
Provider Name (Legal Business Name): HERCULES PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 WOODSON RD
OVERLAND MO
63114-5437
US

IV. Provider business mailing address

2514 WOODSON RD
OVERLAND MO
63114-5437
US

V. Phone/Fax

Practice location:
  • Phone: 314-427-1818
  • Fax: 314-423-9905
Mailing address:
  • Phone: 314-427-1818
  • Fax: 314-423-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2009024559
License Number StateMO

VIII. Authorized Official

Name: BRYAN HERCULES
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 314-427-1818