Provider Demographics
NPI:1184655193
Name:FARRIS, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FARRIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2833
Mailing Address - Country:US
Mailing Address - Phone:573-785-1461
Mailing Address - Fax:573-785-0831
Practice Address - Street 1:1875 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2833
Practice Address - Country:US
Practice Address - Phone:573-785-1461
Practice Address - Fax:573-785-0831
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0804830001Medicare ID - Type UnspecifiedMEDICARE ID #