Provider Demographics
NPI:1659655330
Name:PEACOCK, JERRY WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 W REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4006
Mailing Address - Country:US
Mailing Address - Phone:417-877-8540
Mailing Address - Fax:417-877-8541
Practice Address - Street 1:2681 W REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4006
Practice Address - Country:US
Practice Address - Phone:417-877-8540
Practice Address - Fax:417-877-8541
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO27824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist