Provider Demographics
NPI:1134134745
Name:AFFINIA HEALTHCARE
Entity Type:Organization
Organization Name:AFFINIA HEALTHCARE
Other - Org Name:AFFINIA HEALTHCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-814-8511
Mailing Address - Street 1:2524 HADLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-4019
Mailing Address - Country:US
Mailing Address - Phone:314-814-8570
Mailing Address - Fax:314-814-8590
Practice Address - Street 1:2220 LEMP AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2700
Practice Address - Country:US
Practice Address - Phone:314-814-8570
Practice Address - Fax:314-814-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060042643336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600400717Medicaid
2049151OtherPK