Healthcare Provider Details

I. General information

NPI: 1376890558
Provider Name (Legal Business Name): JACQUELINE MARIE FORD RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S. NATIONAL AVE
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

3231 S. NATIONAL AVE
SPRINGFIELD MO
65807-7304
US

V. Phone/Fax

Practice location:
  • Phone: 417-841-0116
  • Fax: 417-888-5609
Mailing address:
  • Phone: 417-841-0116
  • Fax: 417-888-5609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number29328
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: