Provider Demographics
NPI:1659576205
Name:FOREST PARK PHARMACY
Entity Type:Organization
Organization Name:FOREST PARK PHARMACY
Other - Org Name:FOREST PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAHIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-645-9990
Mailing Address - Street 1:3535 SOUTH JEFFERSON AVE
Mailing Address - Street 2:STE S-1
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3900
Mailing Address - Country:US
Mailing Address - Phone:314-645-9990
Mailing Address - Fax:314-645-9989
Practice Address - Street 1:3535 S. JEFFERSON AVE
Practice Address - Street 2:STE (S-1)
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118
Practice Address - Country:US
Practice Address - Phone:314-645-9990
Practice Address - Fax:314-645-9989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070145503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2637429OtherOTHER ID NUMBER
MO6202750001Medicare NSC