Healthcare Provider Details

I. General information

NPI: 1962852012
Provider Name (Legal Business Name): MAIN SAIL ENTERPRISES SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E PRIMROSE ST STE B
SPRINGFIELD MO
65807-5233
US

IV. Provider business mailing address

655 S CAMPBELL AVE
SPRINGFIELD MO
65806-2901
US

V. Phone/Fax

Practice location:
  • Phone: 417-351-3774
  • Fax: 417-865-1533
Mailing address:
  • Phone: 417-351-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHARLES DAVID KERR
Title or Position: OWNER
Credential: RPH
Phone: 417-351-3774