Provider Demographics
NPI:1730612953
Name:ACCREDO HEALTH GROUP, INC.
Entity type:Organization
Organization Name:ACCREDO HEALTH GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:B
Authorized Official - Last Name:PERINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-684-6273
Mailing Address - Street 1:PO BOX 954041
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-0001
Mailing Address - Country:US
Mailing Address - Phone:901-381-7141
Mailing Address - Fax:901-261-6924
Practice Address - Street 1:2040 W RIO SALADO PKWY
Practice Address - Street 2:STE 101B
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2802
Practice Address - Country:US
Practice Address - Phone:602-944-1199
Practice Address - Fax:602-944-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZY0020743336M0002X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ306060Medicaid
AZ306060Medicaid