Basic Information
| Provider Information | |||||||||
| NPI: | 1790094415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRULL | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23760 BREWER RD | ||||||||
| Address2: | |||||||||
| City: | CROCKER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654528279 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4430 MISSOURI AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LEONARD WOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654739098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735960514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 10580 | AR | N | Pharmacy Service Providers | Pharmacist | 1835P0018X | 10580 | AR | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.