Provider Demographics
NPI:1902881956
Name:MEDICAL WEST PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL WEST PHARMACY INC
Other - Org Name:MEDICAL WEST HEALTHCARE CENTER
Other - Org Type:Doing Business As
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:314-725-1888
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 1:444 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2521
Practice Address - Country:US
Practice Address - Phone:314-725-1888
Practice Address - Fax:314-725-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X
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
MO8200064OtherUNITED HEALTHCARE
MO105140OtherHEALTHLINK
MO29775OtherBLUE CROSS BLUE SHIELD
MO620200907Medicaid
MO850200908Medicaid
MO=========OtherTAX IDENTIFICATION NUMBER
MO29775OtherBLUE CROSS BLUE SHIELD