Provider Demographics
NPI:1700374808
Name:MAH PHARMACY LLC
Entity Type:Organization
Organization Name:MAH PHARMACY LLC
Other - Org Name:CHD PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-858-4916
Mailing Address - Street 1:4600 N HANLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2715
Mailing Address - Country:US
Mailing Address - Phone:314-522-5817
Mailing Address - Fax:314-522-5818
Practice Address - Street 1:4600 N HANLEY RD
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-2715
Practice Address - Country:US
Practice Address - Phone:314-522-5817
Practice Address - Fax:314-522-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20180085063336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177322OtherPK