Provider Demographics
NPI:1376009183
Name:MEDBANK PHARMACY, LLC
Entity Type:Organization
Organization Name:MEDBANK PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HAYTHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:314-662-7597
Mailing Address - Street 1:1003 CENTURY OAKS DR APT H
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1259
Mailing Address - Country:US
Mailing Address - Phone:314-662-7597
Mailing Address - Fax:
Practice Address - Street 1:637 DUNN RD STE 100
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-662-7597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-17
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy