Provider Demographics
NPI:1801039524
Name:PHAR, LLC
Entity Type:Organization
Organization Name:PHAR, LLC
Other - Org Name:AUTUMN RIDGE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-329-4100
Mailing Address - Street 1:7444 LONG AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-3214
Mailing Address - Country:US
Mailing Address - Phone:847-329-4100
Mailing Address - Fax:847-329-7652
Practice Address - Street 1:300 AUTUMN RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:HERCULANEUM
Practice Address - State:MO
Practice Address - Zip Code:63048-1505
Practice Address - Country:US
Practice Address - Phone:636-931-8400
Practice Address - Fax:636-933-3975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-10
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO037148310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM266744705Medicaid