Healthcare Provider Details

I. General information

NPI: 1154425114
Provider Name (Legal Business Name): FITZPATRICK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15394 MANCHESTER RD
BALLWIN MO
63011-3052
US

IV. Provider business mailing address

15394 MANCHESTER RD
BALLWIN MO
63011-3052
US

V. Phone/Fax

Practice location:
  • Phone: 636-394-6622
  • Fax: 636-394-9222
Mailing address:
  • Phone: 636-394-6622
  • Fax: 636-394-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPS006166
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2049588
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier600397301
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 3
Identifier620397307
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MARK RATHGEBER
Title or Position: OWNER
Credential: RPH
Phone: 636-394-6622