Provider Demographics
NPI:1053357566
Name:ST ANTHONYS PROFESSIONAL PHARMACY LLC
Entity type:Organization
Organization Name:ST ANTHONYS PROFESSIONAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VENUTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:314-525-7340
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-525-4488
Mailing Address - Fax:314-525-4810
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 130
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-525-4777
Practice Address - Fax:314-525-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20001600573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600307409Medicaid
2047126OtherPK