Provider Demographics
NPI:1790096683
Name:MERCY HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:MERCY HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR-RETAIL PHARMACY SVCS
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-5606
Mailing Address - Street 1:15945 CLAYTON RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2146
Mailing Address - Country:US
Mailing Address - Phone:636-256-5111
Mailing Address - Fax:636-256-5196
Practice Address - Street 1:15945 CLAYTON RD
Practice Address - Street 2:SUITE 140
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2146
Practice Address - Country:US
Practice Address - Phone:636-256-5111
Practice Address - Fax:636-256-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028453333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790096683Medicaid
MO2639132OtherNCPDP