Provider Demographics
NPI:1093460131
Name:ST. LOUIS JC VAMC
Entity Type:Organization
Organization Name:ST. LOUIS JC VAMC
Other - Org Name:CAPE GIRARDEAU VA CLINIC PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94462
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4462
Mailing Address - Country:US
Mailing Address - Phone:913-578-4409
Mailing Address - Fax:
Practice Address - Street 1:711 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-9998
Practice Address - Country:US
Practice Address - Phone:573-686-9605
Practice Address - Fax:573-778-9787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2647622OtherNCPDP