Provider Demographics
NPI:1619968096
Name:ST LUKES EPISCOPAL PRESBYTERIAN HOSPITAL
Entity Type:Organization
Organization Name:ST LUKES EPISCOPAL PRESBYTERIAN HOSPITAL
Other - Org Name:ST LUKES PHARMACY WINGHAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY SERV
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-205-6291
Mailing Address - Street 1:5551 WINGHAVEN BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3617
Mailing Address - Country:US
Mailing Address - Phone:636-695-2555
Mailing Address - Fax:636-695-2556
Practice Address - Street 1:5551 WINGHAVEN BLVD
Practice Address - Street 2:STE 120
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3617
Practice Address - Country:US
Practice Address - Phone:636-695-2555
Practice Address - Fax:636-695-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080067463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600567515Medicaid
2050270OtherPK