Provider Demographics
NPI:1518560556
Name:HERTER, WILLIAM MARK (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
Last Name:HERTER
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 1:1011 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1081
Mailing Address - Country:US
Mailing Address - Phone:660-263-6710
Mailing Address - Fax:
Practice Address - Street 1:530 EAST 24 HWY
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-6710
Practice Address - Fax:660-263-2269
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist