Healthcare Provider Details

I. General information

NPI: 1336958453
Provider Name (Legal Business Name): CODY JACK GREGORY PHARMACY TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
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

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

V. Phone/Fax

Practice location:
  • Phone: 417-855-1085
  • Fax: 417-855-1086
Mailing address:
  • Phone: 417-855-1085
  • Fax: 417-855-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2024037403
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: