Provider Demographics
NPI:1568753150
Name:MERCY PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:MERCY PHARMACY SERVICES, LLC
Other - Org Name:MERCY PHARMACY SOUTHFORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AMBULATORY & SPECIALTY PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-5607
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-525-4488
Mailing Address - Fax:314-525-4810
Practice Address - Street 1:12700 SOUTHFORK RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-525-4488
Practice Address - Fax:314-525-4810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20120212003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134979OtherPK