Provider Demographics
NPI:1386245991
Name:FARRELL, GENICE
Entity type:Individual
Prefix:
First Name:GENICE
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16335 S 1383 RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3321
Mailing Address - Country:US
Mailing Address - Phone:417-684-0785
Mailing Address - Fax:
Practice Address - Street 1:29 SW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-1772
Practice Address - Country:US
Practice Address - Phone:417-682-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13993183500000X
MO2005040699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist