Provider Demographics
NPI:1548205073
Name:FORUM CENTER PBA PHARMACY
Entity Type:Organization
Organization Name:FORUM CENTER PBA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVISION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-434-2544
Mailing Address - Street 1:67 FORUM SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 FORUM SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3006
Practice Address - Country:US
Practice Address - Phone:314-434-2544
Practice Address - Fax:314-434-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2570333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2605511OtherOTHER ID NUMBER-COMMERCIAL NUMBER