Provider Demographics
NPI:1942801980
Name:SMITH, CODY F
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:F
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0302
Mailing Address - Country:US
Mailing Address - Phone:417-520-1525
Mailing Address - Fax:417-520-1520
Practice Address - Street 1:1320 S GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0302
Practice Address - Country:US
Practice Address - Phone:417-520-1525
Practice Address - Fax:417-520-1520
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017019938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist