Provider Demographics
NPI:1427268655
Name:STL HEALTH RESOURCES CO.
Entity type:Organization
Organization Name:STL HEALTH RESOURCES CO.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER - RETAIL PHARMACY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:319-369-7403
Mailing Address - Street 1:855 A AVE NE STE 110
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5060
Mailing Address - Country:US
Mailing Address - Phone:319-369-7403
Mailing Address - Fax:
Practice Address - Street 1:855 A AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5060
Practice Address - Country:US
Practice Address - Phone:319-369-7403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STL HEALTH RESOURCES CO.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-23
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1321332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0432090010OtherMEDICARE DME SUPPLIER
IAI20972OtherMEDICARE PTAN
IA1427268655Medicaid
IA1623051OtherNCPDP
IA1623051OtherNCPDP