Provider Demographics
NPI:1740596840
Name:KERR, CHARLES DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:KERR
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 1:2586 W CYNTHIA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1311
Mailing Address - Country:US
Mailing Address - Phone:417-343-0635
Mailing Address - Fax:
Practice Address - Street 1:2650 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2037
Practice Address - Country:US
Practice Address - Phone:417-865-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2003031778OtherPHARMACY PERMIT
MO606075505Medicaid
MO5079910001Medicare NSC
MO2003031778OtherPHARMACY PERMIT