Provider Demographics
NPI:1174273114
Name:GOOD GRACES
Entity Type:Organization
Organization Name:GOOD GRACES
Other - Org Name:GOOD GRACES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-855-1085
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265033534OtherNPI
MO600092646Medicaid
FG9836543OtherDEA