Provider Demographics
NPI:1568546307
Name:WHALEYS PHARMACY INC
Entity Type:Organization
Organization Name:WHALEYS PHARMACY INC
Other - Org Name:WHALEY'S SOUTHWEST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRINGHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-634-3606
Mailing Address - Street 1:1431 SOUTHWEST BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2468
Mailing Address - Country:US
Mailing Address - Phone:573-632-2021
Mailing Address - Fax:573-644-7330
Practice Address - Street 1:1431 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2468
Practice Address - Country:US
Practice Address - Phone:573-634-3606
Practice Address - Fax:573-634-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
MO20001435743336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2048333OtherPK
MO600198915Medicaid
MO604791301Medicaid