=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699028415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STE GENEVIEVE COUNTY MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2012
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 BODERMAN SUITE 1E
-----------------------------------------------------
City | BLOOMSDALE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-483-2626
-----------------------------------------------------
Fax | 573-883-1185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 BODERMAN SUITE 1E
-----------------------------------------------------
City | BLOOMSDALE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63627-9099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-483-2626
-----------------------------------------------------
Fax | 573-883-1185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE DIRECTOR
-----------------------------------------------------
Name | AMANDA WOLK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-883-7703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2012036011
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------