Healthcare Provider Details

I. General information

NPI: 1124752563
Provider Name (Legal Business Name): COLBY GROVE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5492 HIGHWAY H UNIT E
PLEASANT HOPE MO
65725-8227
US

IV. Provider business mailing address

5492 HIGHWAY H UNIT E
PLEASANT HOPE MO
65725-8227
US

V. Phone/Fax

Practice location:
  • Phone: 417-840-6912
  • Fax:
Mailing address:
  • Phone: 417-840-6912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2012029728
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: