Basic Information
| Provider Information | |||||||||
| NPI: | 1134422546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DES PERES HEALTHMART PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DES PERES HEALTHMART PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 DOUGHERTY FERRY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149657800 | ||||||||
| FaxNumber: | 3149657802 | ||||||||
| Practice Location | |||||||||
| Address1: | 2345 DOUGHERTY FERRY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149657800 | ||||||||
| FaxNumber: | 3149657802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORDES | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3149657800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 0339 | MO | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2639548 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |