=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619968096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST LUKES EPISCOPAL PRESBYTERIAN HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5551 WINGHAVEN BLVD STE 120
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-3617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-695-2555
-----------------------------------------------------
Fax | 636-695-2556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5551 WINGHAVEN BLVD STE 120
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-3617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-695-2555
-----------------------------------------------------
Fax | 636-695-2556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR OF PHCY SERV
-----------------------------------------------------
Name | RICHARD FOOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-205-6291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2008006746
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------