Healthcare Provider Details

I. General information

NPI: 1124430533
Provider Name (Legal Business Name): CARL HEFNER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 W SOUTH ST
OZARK MO
65721-7329
US

IV. Provider business mailing address

378 PERSIMMON RD
OZARK MO
65721-8164
US

V. Phone/Fax

Practice location:
  • Phone: 417-860-7424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28798
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: