Provider Demographics
NPI:1720497506
Name:PHARMAX MW INC.
Entity Type:Organization
Organization Name:PHARMAX MW INC.
Other - Org Name:PHARMAX PHARMACY #1117
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-954-5510
Mailing Address - Street 1:1117 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2323
Mailing Address - Country:US
Mailing Address - Phone:636-464-1100
Mailing Address - Fax:
Practice Address - Street 1:1117 MAIN ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-2323
Practice Address - Country:US
Practice Address - Phone:636-464-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140276793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7454750001Medicare NSC