=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063919710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLINK HEALTH PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 S WOODS MILL RD STE 100
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-356-2943
-----------------------------------------------------
Fax | 314-558-2641
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 S WOODS MILL RD STE 100
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63017-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-356-2943
-----------------------------------------------------
Fax | 314-558-2641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP, PHARMACY
-----------------------------------------------------
Name | MICHAEL NAMETH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-266-5515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2018011541
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------