Basic Information
| Provider Information | |||||||||
| NPI: | 1700863180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY CARE HEALTH CENTERS PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811615 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 HOLLY HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631112410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144811615 | ||||||||
| FaxNumber: | 3143531310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | MADDOX | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3144811615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 2003004144 | MO | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 606023604 | 05 | MO | MEDICAID | 2003004144 | 01 | MO | MISSOURI PHARMACY LICENSE | OTHER | BF8182254 | 01 | MO | DEA NUMBER | OTHER | 2634978 | 01 | MO | NCPDP | OTHER |