Provider Demographics
NPI:1699028415
Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
Other - Org Name:BLOOMSDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-883-7703
Mailing Address - Street 1:255 BODERMAN
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:BLOOMSDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63627-9099
Mailing Address - Country:US
Mailing Address - Phone:573-483-2626
Mailing Address - Fax:573-883-1185
Practice Address - Street 1:255 BODERMAN
Practice Address - Street 2:SUITE 1E
Practice Address - City:BLOOMSDALE
Practice Address - State:MO
Practice Address - Zip Code:63627
Practice Address - Country:US
Practice Address - Phone:573-483-2626
Practice Address - Fax:573-883-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20120360113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600004992Medicaid
2137520OtherPK