1790096683 NPI number — MERCY HEALTH SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790096683 NPI number — MERCY HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY HEALTH SERVICES, LLC
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:
Provider Other Organization Name Type Code:
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:
1790096683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15945 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-256-5111
Provider Business Mailing Address Fax Number:
636-256-5196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15945 CLAYTON RD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
BALLWIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-256-5111
Provider Business Practice Location Address Fax Number:
636-256-5196
Provider Enumeration Date:
06/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC DIR-RETAIL PHARMACY SVCS
Authorized Official Telephone Number:
314-628-5606

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  2010028453 , 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: 1790096683 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2639132 . This is a "NCPDP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com