MEDICARE: GENESIS PHARMACY SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0004X	Compounding Pharmacy

General Provider Information

NPI Number	:	1356770762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS PHARMACY SERVICES, LLC

Provider Business Mailing Address
First Line	:	1878 CRAIGSHIRE RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4006
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1878 CRAIGSHIRE RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4006
Country	:	US
Telephone Number	:	314-485-8600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FORD MANION
Credential	:
Telephone Number	:	314-485-8600

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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