Provider Demographics
NPI:1629029251
Name:ACCREDO HEALTH GROUP INC
Entity Type:Organization
Organization Name:ACCREDO HEALTH GROUP INC
Other - Org Name:ACCREDO HEALTH GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:VIC
Authorized Official - Middle Name:
Authorized Official - Last Name:PERINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-684-6273
Mailing Address - Street 1:PO BOX 954041
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-0001
Mailing Address - Country:US
Mailing Address - Phone:901-381-7141
Mailing Address - Fax:901-261-6924
Practice Address - Street 1:2040 W RIO SALADO PKWY
Practice Address - Street 2:SUITE 101B
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2802
Practice Address - Country:US
Practice Address - Phone:602-944-1199
Practice Address - Fax:602-944-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336H0001X, 3336S0011X
AZY002074333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ306060Medicaid
AZ690480Medicaid
1989312OtherPK
AZ690480Medicaid