1619902343 NPI number — MARK JAY BECKWITH

Table of content: (NPI 1619902343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619902343 NPI number — MARK JAY BECKWITH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK JAY BECKWITH
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:
BECKWITH 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:
1619902343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63379-0204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 N LINCOLN DR
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63379-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-528-8462
Provider Business Practice Location Address Fax Number:
636-462-6655
Provider Enumeration Date:
07/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BECKWITH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND PHARMACIST
Authorized Official Telephone Number:
636-462-6655

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 3220 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2049617 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 600657803MO , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".