Healthcare Provider Details

I. General information

NPI: 1780191809
Provider Name (Legal Business Name): TIFFANY CHAWNTAY CORYELL RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY CHAWNTAY CRUISE RPH

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 NORTH SCARLETT WAY
SPRINGFIELD MO
65802
US

IV. Provider business mailing address

1134 NORTH SCARLETT WAY
SPRINGFIELD MO
65802
US

V. Phone/Fax

Practice location:
  • Phone: 417-861-1800
  • Fax:
Mailing address:
  • Phone: 417-861-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2004035733
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: