Healthcare Provider Details

I. General information

NPI: 1235186842
Provider Name (Legal Business Name): MERCY HOSPITAL SPRINGFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MAIN ST
LICKING MO
65542-9026
US

IV. Provider business mailing address

101 N MAIN ST
LICKING MO
65542-9026
US

V. Phone/Fax

Practice location:
  • Phone: 573-674-2922
  • Fax: 573-674-4334
Mailing address:
  • Phone: 573-674-2922
  • Fax: 573-674-4334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2011020758
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2011020758
License Number StateMO

VIII. Authorized Official

Name: MR. PATRICK BERRY
Title or Position: EXEC DIR-RETAIL PHARMACY SVCS
Credential:
Phone: 314-628-5606