=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013434851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY PHARMACY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 W MOUNT VERNON ST STE 130
-----------------------------------------------------
City | NIXA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65714-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-724-5340
-----------------------------------------------------
Fax | 417-724-5354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1570 W BATTLEFIELD ST STE 110
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-4163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP AMBULATORY & SPECIAL PHARMACY
-----------------------------------------------------
Name | MR. MARK JAEGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-628-5607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2017027475
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------