1790034064 NPI number — PEVELY RX

Table of content: (NPI 1790034064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790034064 NPI number — PEVELY RX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEVELY RX
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:
THE MEDICINE SHOPPE 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:
1790034064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8640 COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEVELY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63070-1529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-479-6100
Provider Business Mailing Address Fax Number:
636-479-6101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8640 COMMERCIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEVELY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63070-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-479-6100
Provider Business Practice Location Address Fax Number:
636-479-6101
Provider Enumeration Date:
09/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-753-8851

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2012030942 , 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: 2136810 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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