ACARIAHEALTH PHARMACY 12 INC

Provider Demographics

• NPI: 1811206071
• Name: ACARIAHEALTH PHARMACY 12 INC
• Entity Type: Organization
• Organization Name: ACARIAHEALTH PHARMACY 12 INC
• Other - Org Name: ACARIAHEALTH PHARMACY #12
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - First Name: JESSICA
• Authorized Official - Last Name: CICCOLELLA-KAHL
• Authorized Official - Phone: 855-422-2742
• Mailing Address - Street 1: PO BOX 956780
• Mailing Address - City: SAINT LOUIS
• Mailing Address - State: MO
• Mailing Address - Zip Code: 63195-6780
• Mailing Address - Country: US
• Mailing Address - Phone: 855-422-2742
• Practice Address - Street 1: 5 SKYLINE DR STE 240
• Practice Address - City: HAWTHORNE
• Practice Address - State: NY
• Practice Address - Zip Code: 10532-2166
• Practice Address - Country: US
• Practice Address - Phone: 800-511-5144
• Practice Address - Fax: 866-834-8523
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2010-10-05
• Last Update Date: 2024-02-25

Provider Licenses

State	License ID	Taxonomies
		251F00000X
NV	PH02751	3336S0011X
UT	8788455-1708	3336S0011X
RI	PHN10492	3336S0011X
PA	NP000271	3336S0011X
VT	036.0086823	3336S0011X
SC	14829	3336S0011X
TX	27747	3336S0011X
OH	022156100	3336S0011X
ME	MO40001550	3336S0011X
WV	MO0560285	3336S0011X
NH	NR0859	3336S0011X
CT	PCN.0002265	3336S0011X
NJ	28RO00060600	3336S0011X
NY	030446	3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	251F00000X	Agencies	Home Infusion

Provider Identifiers

State	Identifier ID	ID Type	Issuer
UT	1811206071	Medicaid
TN	1811206071	Medicaid
CT	1811206071	Medicaid
PA	103040076 0001	Medicaid
	2133866	Other	PK
NY	3262360	Medicaid
SC	7N0446	Medicaid
NJ	0287865	Medicaid
VT	1021594	Medicaid
OH	0054586	Medicaid
NH	3094449	Medicaid
UT	1811206071	Medicaid
ME	20120149	Medicaid
VT	1021594	Medicaid
PA	103040076 0001	Medicaid