Provider Demographics
NPI:1730244161
Name:IMRAN PHARMACY
Entity type:Organization
Organization Name:IMRAN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:REHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-730-2092
Mailing Address - Street 1:3737 N KINGSHIGHWAY BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-1736
Mailing Address - Country:US
Mailing Address - Phone:314-381-9394
Mailing Address - Fax:314-381-8833
Practice Address - Street 1:3737 N KINGSHIGHWAY BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1736
Practice Address - Country:US
Practice Address - Phone:314-381-9394
Practice Address - Fax:314-381-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 333600000X
MO59953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO608291001AMedicaid
2630780OtherNCPDP PROVIDER IDENTIFICATION NUMBER