=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912506437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E HEALTH PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2020
-----------------------------------------------------
Last Update Date | 10/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411D NORTHVIEW RD
-----------------------------------------------------
City | NIXA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65714-8679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-414-5495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1173 E HINES ST
-----------------------------------------------------
City | REPUBLIC
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65738-1277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-414-5495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | BLAINE ALAN CARTER
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 417-414-5495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------