Provider Demographics
NPI:1619902343
Name:MARK JAY BECKWITH
Entity Type:Organization
Organization Name:MARK JAY BECKWITH
Other - Org Name:BECKWITH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKWITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:636-462-6655
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-0204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 N LINCOLN DR
Practice Address - Street 2:STE 204
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1315
Practice Address - Country:US
Practice Address - Phone:636-528-8462
Practice Address - Fax:636-462-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO32203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049617OtherPK
MO600657803MOMedicaid
2049617OtherPK