=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982764197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALES PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 EAST ROSS ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67026-7821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-584-2025
-----------------------------------------------------
Fax | 620-584-5139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 EAST ROSS ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67026-0459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-584-2025
-----------------------------------------------------
Fax | 620-584-5139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROGER A. BALES
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 620-584-2025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 7399
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------