Healthcare Provider Details

I. General information

NPI: 1588042816
Provider Name (Legal Business Name): MAIN SAIL ENTERPRISES-DOWNTOWN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 S CAMPBELL AVE
SPRINGFIELD MO
65806-2901
US

IV. Provider business mailing address

2101 W CHESTERFIELD BLVD SUITE C100-125
SPRINGFIELD MO
65807-6946
US

V. Phone/Fax

Practice location:
  • Phone: 417-343-0635
  • Fax:
Mailing address:
  • Phone: 417-343-0635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2015012288
License Number StateMO

VIII. Authorized Official

Name: CHARLES DAVID KERR
Title or Position: MEMBER
Credential: RPH
Phone: 417-343-0635