NPIViewer - Provider NPI 1629195045

NPI:	1629195045
Name:	ACARIAHEALTH PHARMACY 11 INC
Entity Type:	Organization
Organization Name:	ACARIAHEALTH PHARMACY 11 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:	JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:	CICCOLELLA-KAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:	855-422-2742
Mailing Address - Street 1:	PO BOX 956780
Mailing Address - Street 2:
Mailing Address - City:	SAINT LOUIS
Mailing Address - State:	MO
Mailing Address - Zip Code:	63195-6780
Mailing Address - Country:	US
Mailing Address - Phone:	855-422-2742
Mailing Address - Fax:	866-834-8523
Practice Address - Street 1:	1311 W SAM HOUSTON PKWY N STE 130
Practice Address - Street 2:
Practice Address - City:	HOUSTON
Practice Address - State:	TX
Practice Address - Zip Code:	77043
Practice Address - Country:	US
Practice Address - Phone:	800-511-5144
Practice Address - Fax:	866-834-8523
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2007-03-22
Last Update Date:	2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	251F00000X	Agencies	Home Infusion
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
Yes	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy

State	Identifier ID	ID Type	Issuer
NE	100264790-00	Medicaid
AZ	709240	Medicaid
GA	003136163A	Medicaid
OH	0161049	Medicaid
KS	200602430A	Medicaid
IN	200921260A	Medicaid
AR	194389407	Medicaid
	2133868	Other	PK
SC	7T5485	Medicaid
NM	86135562	Medicaid
CO	9000143094	Medicaid
OK	200241760A	Medicaid
WA	6031595	Medicaid
TX	146690	Medicaid
AK	1028435	Medicaid
IA	1629195045	Medicaid
MN	1629195045	Medicaid
MN	1629195045	Medicaid