Healthcare Provider Details

I. General information

NPI: 1790034064
Provider Name (Legal Business Name): PEVELY RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8640 COMMERCIAL BLVD
PEVELY MO
63070-1529
US

IV. Provider business mailing address

8640 COMMERCIAL BLVD
PEVELY MO
63070-1529
US

V. Phone/Fax

Practice location:
  • Phone: 636-479-6100
  • Fax: 636-479-6101
Mailing address:
  • Phone: 636-479-6100
  • Fax: 636-479-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2012030942
License Number StateMO

VIII. Authorized Official

Name: DR. JASON ALEXANDER WANG
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 314-753-8851