Healthcare Provider Details

I. General information

NPI: 1306944301
Provider Name (Legal Business Name): MERCY HOSPITAL SPRINGFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR STE 220
ROLLA MO
65401-2980
US

IV. Provider business mailing address

1605 MARTIN SPRINGS DR SUITE 220
ROLLA MO
65401-2931
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6433
  • Fax: 573-458-6441
Mailing address:
  • Phone: 573-458-6433
  • Fax: 573-458-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2006022821
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier606187300
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier2637114
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

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