Provider Demographics
NPI:1700863180
Name:FAMILY CARE HEALTH CENTERS PHARMACY
Entity Type:Organization
Organization Name:FAMILY CARE HEALTH CENTERS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-481-1615
Mailing Address - Street 1:401 HOLLY HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2410
Mailing Address - Country:US
Mailing Address - Phone:314-481-1615
Mailing Address - Fax:314-353-1310
Practice Address - Street 1:401 HOLLY HILLS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-2410
Practice Address - Country:US
Practice Address - Phone:314-481-1615
Practice Address - Fax:314-353-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003004144333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606023604Medicaid
MO2003004144OtherMISSOURI PHARMACY LICENSE
MO2634978OtherNCPDP
MO2634978OtherNCPDP