1427069939 NPI number — MEDICAL ARTS PHARMACY

Table of content: (NPI 1427069939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427069939 NPI number — MEDICAL ARTS PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ARTS PHARMACY
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:
1427069939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1823 WISHWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63090-3415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-239-4368
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 PRAIRIE DELL RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63084-4328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-583-3117
Provider Business Practice Location Address Fax Number:
636-583-3666
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOERS
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
636-239-4368

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: 004795 , 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: 600801120 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2050960 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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