Healthcare Provider Details

I. General information

NPI: 1174908255
Provider Name (Legal Business Name): MICHAEL G HUMPHREY PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8939 COUNTY LANE 213
WEBB CITY MO
64870-7202
US

IV. Provider business mailing address

8939 COUNTY LANE 213
WEBB CITY MO
64870-7202
US

V. Phone/Fax

Practice location:
  • Phone: 417-680-2025
  • Fax: 417-680-2026
Mailing address:
  • Phone: 417-680-2025
  • Fax: 417-680-2026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115457
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number211032453
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: