Healthcare Provider Details

I. General information

NPI: 1508113705
Provider Name (Legal Business Name): BRANDON GREGORY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 03/14/2024
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 E MAIN ST STE 3
WILLOW SPRINGS MO
65793-1500
US

IV. Provider business mailing address

708 ASH ST
WILLOW SPRINGS MO
65793-3445
US

V. Phone/Fax

Practice location:
  • Phone: 417-855-0428
  • Fax:
Mailing address:
  • Phone: 417-855-0428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2012023175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: