Provider Demographics
NPI:1194096701
Name:BAKER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S NATIONAL AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5209
Mailing Address - Country:US
Mailing Address - Phone:417-269-5995
Mailing Address - Fax:
Practice Address - Street 1:3800 S NATIONAL AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5209
Practice Address - Country:US
Practice Address - Phone:417-269-5995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist