Provider Demographics
NPI:1164433710
Name:ST JUDE CHILDREN'S RESEARCH HOSPITAL, INC.
Entity Type:Organization
Organization Name:ST JUDE CHILDREN'S RESEARCH HOSPITAL, INC.
Other - Org Name:ST JUDE HOSPITAL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:D PH MS MBA
Authorized Official - Phone:901-595-2233
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT. 338
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-2237
Practice Address - Fax:901-595-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8433336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2088542OtherPK
MS00330645Medicaid
TN4414431Medicaid
AR145570407Medicaid