MEDICARE: COUNCIL GROVE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1093444119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNCIL GROVE PHARMACY INC

Provider Business Mailing Address
First Line	:	123 W MAIN ST
Second Line	:
City	:	COUNCIL GROVE
State	:	KS
Zip	:	66846-1702
Country	:	US
Telephone Number	:	620-767-6731
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 W MAIN ST
Second Line	:
City	:	COUNCIL GROVE
State	:	KS
Zip	:	66846-1702
Country	:	US
Telephone Number	:	620-767-6731
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LANCE FREEMAN
Credential	:	PHARMD
Telephone Number	:	620-767-6731

Provider Enumeration Date	:	06/06/2022
Last Update Date	:	06/07/2022

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