Provider Demographics
NPI:1376890939
Name:WORRELL, PHILLIP D (RPH, JD)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:D
Last Name:WORRELL
Suffix:
Gender:M
Credentials:RPH, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 CLARKSON EXECUTIVE PARK
Mailing Address - Street 2:SUITE D
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2179
Mailing Address - Country:US
Mailing Address - Phone:636-220-8282
Mailing Address - Fax:636-220-8283
Practice Address - Street 1:130 CLARKSON EXECUTIVE PARK
Practice Address - Street 2:SUITE D
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2179
Practice Address - Country:US
Practice Address - Phone:636-220-8282
Practice Address - Fax:636-220-8283
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO42479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist