Provider Demographics
NPI:1962003921
Name:TEETER, JUSTIN ERIC (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ERIC
Last Name:TEETER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 US HIGHWAY 60 E
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1580
Mailing Address - Country:US
Mailing Address - Phone:417-732-1476
Mailing Address - Fax:417-732-6828
Practice Address - Street 1:1150 US HIGHWAY 60 E
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1580
Practice Address - Country:US
Practice Address - Phone:417-732-1476
Practice Address - Fax:417-732-6828
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist