Provider Demographics
NPI:1033185186
Name:AETNA RX HOME DELIVERY, LLC
Entity Type:Organization
Organization Name:AETNA RX HOME DELIVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR, PHARMACIST - IN -CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEHAEMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:959-299-2941
Mailing Address - Street 1:10991 NW AIRWORLD DR
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64153-2011
Mailing Address - Country:US
Mailing Address - Phone:866-612-3862
Mailing Address - Fax:877-270-3317
Practice Address - Street 1:10991 NW AIRWORLD DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-2011
Practice Address - Country:US
Practice Address - Phone:866-612-3862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003001979333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2003001979OtherMISSOURI LICENSE
MO2003001979OtherMISSOURI LICENSE
MO2003001979OtherMISSOURI LICENSE