Provider Demographics
NPI:1407163736
Name:ACCREDO HEALTH GROUP INC
Entity Type:Organization
Organization Name:ACCREDO HEALTH GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:VIC
Authorized Official - Middle Name:
Authorized Official - Last Name:PERINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-684-6273
Mailing Address - Street 1:PO BOX 954041
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-0001
Mailing Address - Country:US
Mailing Address - Phone:901-381-7141
Mailing Address - Fax:901-261-6924
Practice Address - Street 1:2410 WARDLOW RD STE 101
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92878-5192
Practice Address - Country:US
Practice Address - Phone:951-737-2355
Practice Address - Fax:951-737-2553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50860333600000X
3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240344Medicaid
WA6021265Medicaid
MT1952359150Medicaid
HI508187Medicaid
CAPHA462820Medicaid
WA7331457Medicaid
OR028499Medicaid
2126625OtherPK
ID808279200Medicaid
OR240344Medicaid