Healthcare Provider Details

I. General information

NPI: 1194917773
Provider Name (Legal Business Name): SPECIALTY PHARMACY OF ST. LOUIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 N NEW BALLAS RD
CREVE COEUR MO
63141-6713
US

IV. Provider business mailing address

623 N NEW BALLAS RD
CREVE COEUR MO
63141-6713
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-5200
  • Fax: 314-991-5210
Mailing address:
  • Phone: 314-991-5200
  • Fax: 314-991-5210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2003001140
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number2003001140
License Number StateMO

VIII. Authorized Official

Name: DR. LEE ERIC ORI
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 314-991-5200