Provider Demographics
NPI:1215812664
Name:COFFMAN, BROCK
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:COFFMAN
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 1:128 E DEER RUN ST
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-7553
Mailing Address - Country:US
Mailing Address - Phone:417-259-2761
Mailing Address - Fax:
Practice Address - Street 1:106 N UNION ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1724
Practice Address - Country:US
Practice Address - Phone:417-926-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025031843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist