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General NPI Number Information
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NPI Number | 1184092793
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Entity Type | Organization
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Legal Business Name | C&P VIBURNUM VENTURES LLC
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 04/27/2023
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Provider Practice Location Address
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Address Line | 1 VIBURNUM CENTER RD STE B
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City | VIBURNUM
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State | MO
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Zip | 65566-7802
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Country | US
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Telephone | 573-244-3784
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Fax | 573-244-3700
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Provider Business Mailing Address
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Address Line | 450 COUNTY ROAD 139
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City | ALTON
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State | MO
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Zip | 65606-8221
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Country | US
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Telephone | 573-244-3784
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Fax | 573-244-3700
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Authorized Official
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Title or Position | OWNER-RPH
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Name | REBECA WALTERS-PEACE
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Credential |
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Telephone | 417-778-6807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 2015037740
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License Number State | MO
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