Provider Demographics
NPI:1265033534
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:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
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:2020-11-03
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600092646Medicaid
MO2500065241OtherSTATE BUREAU OF NARCOTICS AND DANGEROUS DRUGS
MO2020037376OtherSTATE BOARD OF PHARMACY PERMIT