Provider Demographics
NPI:1982770640
Name:WHALEYS PHARMACY INC
Entity Type:Organization
Organization Name:WHALEYS PHARMACY INC
Other - Org Name:WHALEYS WEST SIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEBRUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-659-0650
Mailing Address - Street 1:1431 SOUTHWEST BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2468
Mailing Address - Country:US
Mailing Address - Phone:573-659-0650
Mailing Address - Fax:573-659-0651
Practice Address - Street 1:3526 AMAZONAS DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5716
Practice Address - Country:US
Practice Address - Phone:573-659-0650
Practice Address - Fax:573-659-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20050045213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600198931Medicaid
2049072OtherPK