Provider Demographics
NPI:1518150150
Name:ST JOHN'S REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:ST JOHN'S REGIONAL HEALTH CENTER
Other - Org Name:ST JOHN'S PHARMACY-NIXA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-2520
Mailing Address - Street 1:940 W MOUNT VERNON ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9609
Mailing Address - Country:US
Mailing Address - Phone:417-724-5350
Mailing Address - Fax:417-724-5354
Practice Address - Street 1:940 W MOUNT VERNON ST
Practice Address - Street 2:SUITE 130
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-9609
Practice Address - Country:US
Practice Address - Phone:417-724-5350
Practice Address - Fax:417-724-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005012026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626198402Medicaid