1659576205 NPI number — FOREST PARK PHARMACY

Table of content: (NPI 1659576205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659576205 NPI number — FOREST PARK PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREST PARK PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOREST PARK PHARMACY
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 Information

NPI Number:
1659576205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 SOUTH JEFFERSON AVE
Provider Second Line Business Mailing Address:
STE S-1
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63118-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-645-9990
Provider Business Mailing Address Fax Number:
314-645-9989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 S. JEFFERSON AVE
Provider Second Line Business Practice Location Address:
STE (S-1)
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-645-9990
Provider Business Practice Location Address Fax Number:
314-645-9989
Provider Enumeration Date:
06/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JAHIC
Authorized Official First Name:
AMIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
314-645-9990

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2007014550 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2637429 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".