MEDICARE: CODY JACK GREGORY PHARMACY TECH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	19331	MO
2	183700000X	Pharmacy Technician	2024037403	MO

General Provider Information

NPI Number	:	1336958453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY JACK GREGORY PHARMACY TECH

Provider Business Mailing Address
First Line	:	857 E MAIN ST STE 3
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-1500
Country	:	US
Telephone Number	:	417-855-1085
Fax Number	:	417-855-1086

Provider Business Practice Location Address
First Line	:	857 E MAIN ST STE 3
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-1500
Country	:	US
Telephone Number	:	417-855-1085
Fax Number	:	417-855-1086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2025
Last Update Date	:	04/07/2026

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