Provider Demographics
NPI:1104066778
Name:MEDICAL WEST PHARMACY, INC
Entity type:Organization
Organization Name:MEDICAL WEST PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-7900
Mailing Address - Street 1:9301 DIELMAN INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2204
Mailing Address - Country:US
Mailing Address - Phone:314-993-7900
Mailing Address - Fax:314-569-5056
Practice Address - Street 1:19 RONNIES PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3552
Practice Address - Country:US
Practice Address - Phone:314-290-2200
Practice Address - Fax:314-902-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO850200908320900000X
MO10803009332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
612829OtherHEALTHLINK
MO620200907Medicaid
MO181658OtherANTHEM BLUE CROSS BLUE SHIELD
MO181658OtherANTHEM BLUE CROSS BLUE SHIELD