Healthcare Provider Details

I. General information

NPI: 1275615064
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: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E PRIMROSE ST
SPRINGFIELD MO
65807-5155
US

IV. Provider business mailing address

1522 E SUNSHINE ST
SPRINGFIELD MO
65804-1214
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-6800
  • Fax: 417-883-3006
Mailing address:
  • Phone: 417-881-2910
  • Fax: 417-890-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number004562
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2623038
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER
# 2
Identifier600309827
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

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