=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629279914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOHNS MERCY MEDSCRIPT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13185 LAKEFRONT DR SUITE 100
-----------------------------------------------------
City | EARTH CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63045-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-506-6066
-----------------------------------------------------
Fax | 314-506-6067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13185 LAKEFRONT DR SUITE 100
-----------------------------------------------------
City | EARTH CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63045-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-506-6066
-----------------------------------------------------
Fax | 314-506-6067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF OPERATIONS
-----------------------------------------------------
Name | MR. TOM E EDELSTEIN
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 314-729-4668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2000175014
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------