Healthcare Provider Details

I. General information

NPI: 1457606824
Provider Name (Legal Business Name): ADRIENNE JILL GOBLE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NORTH MAIN ST
LICKING MO
65542-9026
US

IV. Provider business mailing address

101 NORTH MAIN ST PO BOX 125
LICKING MO
65542
US

V. Phone/Fax

Practice location:
  • Phone: 573-674-3932
  • Fax: 573-674-4334
Mailing address:
  • Phone: 573-674-3932
  • Fax: 573-674-4334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2004034224
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: