=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912651761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY LATHAM PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2022
-----------------------------------------------------
Last Update Date | 02/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 SW 3RD ST
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64063-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-524-5084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7315 W 57TH ST
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66202-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-522-0237
-----------------------------------------------------
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 | 2014021635
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------