MEDICARE: HERMITAGE PROFESSIONAL ENTERPRISES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	004831	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2050737	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528169083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERMITAGE PROFESSIONAL ENTERPRISES INC

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	HERMITAGE
State	:	MO
Zip	:	65668
Country	:	US
Telephone Number	:	417-745-2136
Fax Number	:	417-745-2130

Provider Business Practice Location Address
First Line	:	23649 DALLAS ST
Second Line	:
City	:	HERMITAGE
State	:	MO
Zip	:	65668-9231
Country	:	US
Telephone Number	:	417-745-2136
Fax Number	:	417-745-2130

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AL NYBERG
Credential	:
Telephone Number	:	417-745-2136

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	09/19/2025

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Directions to “HERMITAGE PROFESSIONAL ENTERPRISES INC ” Practice Location

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