=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093558009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1101A NORTH JEFFERSON PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2024
-----------------------------------------------------
Last Update Date | 06/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101A N JEFFERSON AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63106-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-242-8844
-----------------------------------------------------
Fax | 636-242-8822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 S BEMISTON AVE STE 850
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-1920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-242-8844
-----------------------------------------------------
Fax | 636-242-8822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MRS. SANDRA JAMRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 636-242-8844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------