Healthcare Provider Details

I. General information

NPI: 1396895611
Provider Name (Legal Business Name): MAIN SAIL ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 HIGH ST
SARCOXIE MO
64862-8323
US

IV. Provider business mailing address

PO BOX 267
SARCOXIE MO
64862-0267
US

V. Phone/Fax

Practice location:
  • Phone: 417-548-7184
  • Fax: 417-548-7404
Mailing address:
  • Phone: 417-548-7184
  • Fax: 417-548-7404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2012010519
License Number StateMO

VIII. Authorized Official

Name: CHARLES KERR
Title or Position: OWNER
Credential:
Phone: 417-548-7184