Healthcare Provider Details

I. General information

NPI: 1538926639
Provider Name (Legal Business Name): COUNCIL GROVE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W MAIN ST
COUNCIL GROVE KS
66846-1702
US

IV. Provider business mailing address

123 W MAIN ST
COUNCIL GROVE KS
66846-1702
US

V. Phone/Fax

Practice location:
  • Phone: 620-767-6731
  • Fax: 620-767-6858
Mailing address:
  • Phone: 620-767-6731
  • Fax: 620-767-6858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LANCE MICHAEL FREEMAN
Title or Position: OWNER
Credential:
Phone: 620-767-6731