Provider Demographics
NPI:1790034064
Name:PEVELY RX
Entity type:Organization
Organization Name:PEVELY RX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:314-753-8851
Mailing Address - Street 1:8640 COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PEVELY
Mailing Address - State:MO
Mailing Address - Zip Code:63070-1529
Mailing Address - Country:US
Mailing Address - Phone:636-479-6100
Mailing Address - Fax:636-479-6101
Practice Address - Street 1:8640 COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:PEVELY
Practice Address - State:MO
Practice Address - Zip Code:63070-1529
Practice Address - Country:US
Practice Address - Phone:636-479-6100
Practice Address - Fax:636-479-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-02
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X
MO20120309423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136810OtherPK
MO606585404Medicaid