Provider Demographics
NPI:1558909150
Name:DEDICATED MISSOURI HOLDING, LLC
Entity Type:Organization
Organization Name:DEDICATED MISSOURI HOLDING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-628-6117
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3649 PAGE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3807
Practice Address - Country:US
Practice Address - Phone:314-328-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEDICATED MISSOURI HOLDING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site