Provider Demographics
NPI:1639650849
Name:CRADER, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:CRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:LEABU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 OSAGE DR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-8062
Mailing Address - Country:US
Mailing Address - Phone:573-270-5121
Mailing Address - Fax:
Practice Address - Street 1:411 OSAGE DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730-8062
Practice Address - Country:US
Practice Address - Phone:573-270-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist