Provider Demographics
NPI:1932175965
Name:SPARKS, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:SPARKS
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:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0033
Mailing Address - Country:US
Mailing Address - Phone:417-326-7455
Mailing Address - Fax:417-326-7757
Practice Address - Street 1:2000B S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9654
Practice Address - Country:US
Practice Address - Phone:417-326-7455
Practice Address - Fax:417-326-7757
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4790300001Medicare ID - Type Unspecified