=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932175965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFF SPARKS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000B S SPRINGFIELD AVE
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613-9654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-326-7455
-----------------------------------------------------
Fax | 417-326-7757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613-0033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-326-7455
-----------------------------------------------------
Fax | 417-326-7757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 005482
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------