Provider Demographics
NPI:1780076315
Name:MALLINSON, CHARLES MATTHEW (PD, RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:MALLINSON
Suffix:
Gender:M
Credentials:PD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 N RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:64050-1105
Mailing Address - Country:US
Mailing Address - Phone:816-590-7979
Mailing Address - Fax:
Practice Address - Street 1:3118 N RIVER BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR CREEK
Practice Address - State:MO
Practice Address - Zip Code:64050-1105
Practice Address - Country:US
Practice Address - Phone:816-590-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist