Provider Demographics
NPI:1013021328
Name:SPARKS PHARMACY INC
Entity Type:Organization
Organization Name:SPARKS PHARMACY INC
Other - Org Name:BOLIVAR DRUG COMPOUNDING AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-777-7455
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0033
Mailing Address - Country:US
Mailing Address - Phone:417-777-7455
Mailing Address - Fax:417-777-7455
Practice Address - Street 1:2000 S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9654
Practice Address - Country:US
Practice Address - Phone:417-777-7455
Practice Address - Fax:417-777-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO0054823336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137787OtherPK