1407807191 NPI number — ACCREDO HEALTH GROUP INC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407807191 NPI number — ACCREDO HEALTH GROUP INC

Employer Identification Number (EIN):

Provider Organization Name:

ACCREDO HEALTH GROUP INC

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

ACCREDO HEALTH GROUP INC

Provider Other Organization Name Type Code:

3

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1407807191

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

10/07/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 954041

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SAINT LOUIS

Provider Business Mailing Address State Name:

MO

Provider Business Mailing Address Postal Code:

63195-0001

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

901-381-7141

Provider Business Mailing Address Fax Number:

901-261-6924

Provider First Line Business Practice Location Address:

422 GALLIMORE DAIRY RD

Provider Second Line Business Practice Location Address:

SUITE A

Provider Business Practice Location Address City Name:

GREENSBORO

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

27409-9725

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

336-393-0555

Provider Business Practice Location Address Fax Number:

866-832-3709

Provider Enumeration Date:

05/15/2006

Authorized Official Last Name:

PERINI

Authorized Official First Name:

VIC

Authorized Official Middle Name:

Authorized Official Title or Position:

ASSISTANT SECRETARY

Authorized Official Telephone Number:

314-684-6273

• Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 333600000X , with the licence number: 09140 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 0417781 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 1407807191 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 8535 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: DE1236 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 2070156 . This is a "PK" identifier . This identifiers is of the category "OTHER".
• Identifier: 7N8089 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 7702102 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 1508024 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 6800386 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".