Provider Demographics
NPI:1629595491
Name:MERCY PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:MERCY PHARMACY SERVICES, LLC
Other - Org Name:MERCY PHARMACY ST ROBERT
Other - Org Type:Other Name
Authorized Official - Title/Position:VP AMBULATORY & SPECIALTY PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-5607
Mailing Address - Street 1:1570 W BATTLEFIELD ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:586 OLD ROUTE 66
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3729
Practice Address - Country:US
Practice Address - Phone:573-336-2180
Practice Address - Fax:573-336-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO183500000X
MO2017027480333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2634815OtherNCPDP
MO605986702Medicaid