Healthcare Provider Details

I. General information

NPI: 1639771934
Provider Name (Legal Business Name): KELSEY CISSELL PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 S PERRYVILLE BLVD
PERRYVILLE MO
63775-6156
US

IV. Provider business mailing address

816 JENKINS ST
PERRYVILLE MO
63775-1121
US

V. Phone/Fax

Practice location:
  • Phone: 573-547-2577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015029229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: