=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568729150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 07/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 S NEW BALLAS RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-8221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-251-6900
-----------------------------------------------------
Fax | 314-251-6899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 S NEW BALLAS RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-8221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-251-6900
-----------------------------------------------------
Fax | 314-251-6899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER EAST COMMUNITY
-----------------------------------------------------
Name | MR. JOHN P HYATT
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 314-251-7445
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------