Provider Demographics
NPI:1073119806
Name:HERNDON, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:HERNDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N FOREST AVE APT 3209
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2467
Mailing Address - Country:US
Mailing Address - Phone:314-401-7007
Mailing Address - Fax:
Practice Address - Street 1:601 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8513
Practice Address - Country:US
Practice Address - Phone:816-635-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist