1235124165 NPI number — MED RESOURCES RETAIL, LLC

Table of content: (NPI 1235124165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235124165 NPI number — MED RESOURCES RETAIL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED RESOURCES RETAIL, 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:
6
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:
1235124165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15464 OLIVE BOULEVARD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63017-1719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-530-4500
Provider Business Mailing Address Fax Number:
636-530-4577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15464 OLIVE BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-530-4500
Provider Business Practice Location Address Fax Number:
636-530-4577
Provider Enumeration Date:
09/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRAUN
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
636-733-7200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 626238505 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com