1255932315 NPI number — MR. SAMUEL LEE BROCK PHARMACIST

Table of content: MR. SAMUEL LEE BROCK PHARMACIST (NPI 1255932315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255932315 NPI number — MR. SAMUEL LEE BROCK PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
SAMUEL
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255932315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 1 BOX 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANZANT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65768-9704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-948-2383
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65711-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-926-4129
Provider Business Practice Location Address Fax Number:
417-926-7578
Provider Enumeration Date:
11/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  2003029964 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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