Healthcare Provider Details

I. General information

NPI: 1366524159
Provider Name (Legal Business Name): GROVE PROFESSIONAL PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 S NATIONAL AVE, STE 109
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

1925 S GLENSTONE AVE
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-2910
  • Fax: 417-881-3014
Mailing address:
  • Phone: 417-881-2910
  • Fax: 417-890-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number003203
License Number StateMO

VIII. Authorized Official

Name: GARY GROVE
Title or Position: PRES
Credential:
Phone: 417-881-2910