=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720091598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL VILLAGE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 06/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7945 BIG BEND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-962-1065
-----------------------------------------------------
Fax | 314-962-9215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7945 BIG BEND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 314-962-9215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST
-----------------------------------------------------
Name | MR. EUGENE ADAM ARBINI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 314-962-1065
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 002541
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------