=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316548928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMIAH HERBERT PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 BRANSON HILLS PKWY
-----------------------------------------------------
City | BRANSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65616-9942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-334-2804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 CURRY LN
-----------------------------------------------------
City | GALENA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65656-8617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2011023421
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------