Basic Information
| Provider Information | |||||||||
| NPI: | 1801039524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHAR, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AUTUMN RIDGE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7444 LONG AVE | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | 8473297652 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 AUTUMN RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HERCULANEUM | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630481505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369318400 | ||||||||
| FaxNumber: | 6369333975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2009 | ||||||||
| LastUpdateDate: | 07/28/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8473294100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 037148 | MO | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | M266744705 | 05 | MO | MEDICAID |