Provider Demographics
NPI:1558067199
Name:PRISM MOLECULAR LLC
Entity Type:Organization
Organization Name:PRISM MOLECULAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-952-2370
Mailing Address - Street 1:140 ENCHANTED PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5491
Mailing Address - Country:US
Mailing Address - Phone:314-952-3261
Mailing Address - Fax:
Practice Address - Street 1:1801 MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447-1365
Practice Address - Country:US
Practice Address - Phone:570-382-8125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory