Provider Demographics
NPI:1629578927
Name:PACIFIC RX INC
Entity Type:Organization
Organization Name:PACIFIC RX INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-609-2605
Mailing Address - Street 1:2290 W OSAGE ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-1131
Mailing Address - Country:US
Mailing Address - Phone:636-257-9777
Mailing Address - Fax:636-257-9774
Practice Address - Street 1:2290 W OSAGE ST
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069-1131
Practice Address - Country:US
Practice Address - Phone:636-257-9777
Practice Address - Fax:636-257-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MO20180042323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175917OtherPK