Provider Demographics
NPI:1033217880
Name:MEDICAL WEST PHARMCAY, INC
Entity Type:Organization
Organization Name:MEDICAL WEST PHARMCAY, INC
Other - Org Name:MEDICAL WEST HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:LANE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:314-993-7900
Mailing Address - Street 1:9301 DIELMAN INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2204
Mailing Address - Country:US
Mailing Address - Phone:314-993-7900
Mailing Address - Fax:
Practice Address - Street 1:4630 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1607
Practice Address - Country:US
Practice Address - Phone:636-477-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6903OtherGROUP HEALTH PLAN
MO29775OtherBLUECROSS BLUE SHIELD MO
MO=========DMEOtherMERCY HEALTH PLAN
MO6903OtherGROUP HEALTH PLAN
MO6903OtherGROUP HEALTH PLAN