Pevely RX
Organization Active NPI Community/Retail Pharmacy · Pevely, MO
NPI 1790034064 · NPPES record last updated Jun 10, 2024
Key facts
- NPI
- 1790034064
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 2012030942 (MO)
- Legal business name
- PEVELY RX
- Practice address
- 8640 Commercial Blvd
Pevely, MO 63070-1529 - Phone
- (636) 479-6100
- Fax
- (636) 479-6101
- NPI assigned
- Sep 2, 2012
- Organization subpart
- No
Authorized official
- Name
- Dr. Jason Alexander Wang, PHARMD
- Title
- President
- Phone
- (314) 753-8851
Corporate family (same tax ID) 1
Practitioners 7
-
Hollie Marie Roedel, PHARMD
-
Victoria Lynn Viehman, PHARMD
-
Jason Alexander Wang, PHARM.D.
-
Erin Marie Ditch, PHARMD
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20160324001947 | MO | Part B Supplier - Mass Immunization (Roster Biller Only) | 6002113669 | Practice locations: Pevely, MO |
| O20190513001047 | MO | Part B Supplier - Pharmacy | 6002113669 | Practice locations: Pevely, MO |
National Provider Directory
- Tax ID family
- Pevely RX
Locations
8640 Commercial Blvd
Pevely, MO 63070
Phone (636) 479-6100
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 2012030942 | MO | Yes |
| Compounding Pharmacy | 3336C0004X | |||
| Long Term Care Pharmacy | 3336L0003X |
Addresses
Primary practice location
8640 Commercial Blvd
Pevely, MO 63070-1529
Mailing address
8640 Commercial Blvd
Pevely, MO 63070-1529
Phone (636) 479-6100
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2136810 | Other | PK | |
| 606585404 | Medicaid | MO |
Other names
- The Medicine Shoppe Pharmacy
Other providers in Pevely, MO
- John C Druhe DDS PC
- Kinematic Concepts LLC
- Madonna Ann McFarland
- Emily Paszkiewicz
- Pevely RX
- Haylie Pham
- Hollie Marie Roedel
- Todd Wind DDS Dba Pevely Family Dentistry
- Kelly N Uding
- Victoria Lynn Viehman
All providers in Pevely, MO · Community/Retail Pharmacy in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 10, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.