Provider Demographics
NPI:1255932315
Name:BROCK, SAMUEL LEE (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 425
Mailing Address - Street 2:
Mailing Address - City:VANZANT
Mailing Address - State:MO
Mailing Address - Zip Code:65768-9704
Mailing Address - Country:US
Mailing Address - Phone:417-948-2383
Mailing Address - Fax:
Practice Address - Street 1:2100 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-2438
Practice Address - Country:US
Practice Address - Phone:417-926-4129
Practice Address - Fax:417-926-7578
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
MO2003029964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist