Healthcare Provider Details

I. General information

NPI: 1992910442
Provider Name (Legal Business Name): DARRELL JAMES SHIRK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 KIDWELL DR
VERSAILLES MO
65084-1784
US

IV. Provider business mailing address

177 GREENES PT
GRAVOIS MILLS MO
65037-8024
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-4661
  • Fax: 573-378-5053
Mailing address:
  • Phone: 573-374-6882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2003000273
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: