{
"Npi": {
"NPI": "1629279914",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ST JOHNS MERCY MEDSCRIPT, INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "13185 LAKEFRONT DR",
"SecondLineMailingAddress": "SUITE 100",
"MailingAddressCityName": "EARTH CITY",
"MailingAddressStateName": "MO",
"MailingAddressPostalCode": "63045-1510",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "314-506-6066",
"MailingAddressFaxNumber": "314-506-6067",
"FirstLinePracticeLocationAddress": "13185 LAKEFRONT DR",
"SecondLinePracticeLocationAddress": "SUITE 100",
"PracticeLocationAddressCityName": "EARTH CITY",
"PracticeLocationAddressStateName": "MO",
"PracticeLocationAddressPostalCode": "63045-1510",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "314-506-6066",
"PracticeLocationAddressFaxNumber": "314-506-6067",
"EnumerationDate": "05/31/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EDELSTEIN",
"AuthorizedOfficialFirstName": "TOM",
"AuthorizedOfficialMiddleName": "E",
"AuthorizedOfficialTitle": "VICE PRESIDENT OF OPERATIONS",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MBA",
"AuthorizedOfficialTelephoneNumber": "314-729-4668",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "2000175014",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}