Provider Demographics
NPI:1104427624
Name:CUNNINGHAM, LEE OWEN (PHARMD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:OWEN
Last Name:CUNNINGHAM
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 1:323 E GRAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1447
Mailing Address - Country:US
Mailing Address - Phone:417-761-6350
Mailing Address - Fax:417-761-6351
Practice Address - Street 1:323 E GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1447
Practice Address - Country:US
Practice Address - Phone:417-761-6350
Practice Address - Fax:417-761-6351
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160240011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0000Medicaid