1720079551 NPI number — ST CLAIR REXALL DRUG STORE

Table of content: (NPI 1720079551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720079551 NPI number — ST CLAIR REXALL DRUG STORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CLAIR REXALL DRUG STORE
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:
ST. CLAIR HEALTH MART 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:
1720079551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
855 N COMMERCIAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63077-1118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-629-0710
Provider Business Mailing Address Fax Number:
636-629-4408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 N COMMERCIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLAIR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63077-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-629-0710
Provider Business Practice Location Address Fax Number:
636-629-4408
Provider Enumeration Date:
11/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LINDEMANN
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
636-629-0710

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  002865 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 2865 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; 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: 2610271 . This is a "NABP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 620245100 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600245104 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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