Provider Demographics
NPI:1235186842
Name:MERCY HOSPITAL SPRINGFIELD
Entity Type:Organization
Organization Name:MERCY HOSPITAL SPRINGFIELD
Other - Org Name:MERCY PHARMACY-LICKING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR-RETAIL PHARMACY SVCS
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-5606
Mailing Address - Street 1:101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-9026
Mailing Address - Country:US
Mailing Address - Phone:573-674-2922
Mailing Address - Fax:573-674-4334
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9026
Practice Address - Country:US
Practice Address - Phone:573-674-2922
Practice Address - Fax:573-674-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020758183500000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2608466OtherNCPDP #
MO600054100Medicaid
MO2608466OtherNCPDP #