Provider Demographics
NPI:1316257199
Name:CALLAHAN, JERRY W (RPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:CALLAHAN
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 1:106 BROADWAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:ELSBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:63343-1345
Mailing Address - Country:US
Mailing Address - Phone:573-898-2550
Mailing Address - Fax:573-898-5730
Practice Address - Street 1:106 BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:ELSBERRY
Practice Address - State:MO
Practice Address - Zip Code:63343-1345
Practice Address - Country:US
Practice Address - Phone:573-898-2550
Practice Address - Fax:573-898-5730
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist