Provider Demographics
NPI:1336892025
Name:BRUCE, CHARLES TAYLOR JR (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TAYLOR
Last Name:BRUCE
Suffix:JR
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 1:11202 BROME DR
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-7349
Mailing Address - Country:US
Mailing Address - Phone:816-517-9890
Mailing Address - Fax:
Practice Address - Street 1:94 CECIL ST
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-7057
Practice Address - Country:US
Practice Address - Phone:573-346-2992
Practice Address - Fax:573-346-2933
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist