Provider Demographics
NPI:1710404264
Name:MERCY PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:MERCY PHARMACY SERVICES, LLC
Other - Org Name:MERCY PHARMACY LEBANON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AMBULATORY & SPECIALTY PHARMACY
Authorized Official - Prefix:
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 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9215
Practice Address - Country:US
Practice Address - Phone:417-533-6770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20170274823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049004OtherPK
MO600095004Medicaid