Healthcare Provider Details

I. General information

NPI: 1710965504
Provider Name (Legal Business Name): BARTON KEENE EASTERLY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 E EVERGREEN CHRISTIAN HEALTH CARE PHARMACY
SPRINGFIELD MO
65803
US

IV. Provider business mailing address

4758 N PINE HAVEN RD
NIXA MO
65714
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-6357
  • Fax: 417-823-3870
Mailing address:
  • Phone: 417-724-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number042613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: