Healthcare Provider Details

I. General information

NPI: 1043308497
Provider Name (Legal Business Name): ST. JOHN'S CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WEST 10TH STREET SUITE 150
ROLLA MO
65401
US

IV. Provider business mailing address

1100 WEST 10TH STREET SUITE 150
ROLLA MO
65401
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-4931
  • Fax: 573-426-4932
Mailing address:
  • Phone: 573-426-4931
  • Fax: 573-426-4932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2006027507
License Number StateMO

VIII. Authorized Official

Name: MR. ROB D SHOCKLEY
Title or Position: RETAIL PHARMACY COORDINATOR
Credential: RPH
Phone: 417-820-6624