Provider Demographics
NPI:1982644514
Name:MERCY HOSPITAL SPRINGFIELD
Entity Type:Organization
Organization Name:MERCY HOSPITAL SPRINGFIELD
Other - Org Name:MERCY PHARMACY-FREMONT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR-RETAIL PHARMACY SVCS
Authorized Official - Prefix:MR
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 1:1235 E CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2203
Mailing Address - Country:US
Mailing Address - Phone:417-820-2754
Mailing Address - Fax:417-820-7788
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-3577
Practice Address - Fax:417-820-3578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006618183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601847809Medicaid
MO2620284OtherNABP
MO601847809Medicaid