Provider Demographics
NPI:1336958453
Name:GREGORY, CODY JACK (PHARMACY TECH)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:JACK
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PHARMACY TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 E MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65793-1500
Mailing Address - Country:US
Mailing Address - Phone:417-855-1085
Mailing Address - Fax:417-855-1086
Practice Address - Street 1:857 E MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:65793-1500
Practice Address - Country:US
Practice Address - Phone:417-855-1085
Practice Address - Fax:417-855-1086
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024037403183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician