Provider Demographics
NPI:1114268935
Name:BJC BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:BJC BEHAVIORAL HEALTH
Other - Org Name:BJC BEHAVIORAL SOUTHEAST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-206-3712
Mailing Address - Street 1:1085 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1955
Mailing Address - Country:US
Mailing Address - Phone:573-756-5353
Mailing Address - Fax:
Practice Address - Street 1:1085 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1955
Practice Address - Country:US
Practice Address - Phone:573-756-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BJC BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-04
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No251S00000XAgenciesCommunity/Behavioral Health