Healthcare Provider Details

I. General information

NPI: 1053063172
Provider Name (Legal Business Name): RICHARD BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13655 N STATE HIGHWAY 5
SUNRISE BEACH MO
65079-7449
US

IV. Provider business mailing address

13655 N STATE HIGHWAY 5
SUNRISE BEACH MO
65079-7449
US

V. Phone/Fax

Practice location:
  • Phone: 573-372-8305
  • Fax: 573-372-8308
Mailing address:
  • Phone: 573-372-8305
  • Fax: 573-372-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number043888
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: