Basic Information
| Provider Information | |||||||||
| NPI: | 1346208949 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCREDO HEALTH GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ACCREDO HEALTH GROUP INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 954041 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013817141 | ||||||||
| FaxNumber: | 9012616924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 CENTURY CENTER PKWY STE 109 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381348849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013853600 | ||||||||
| FaxNumber: | 9013853777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERINI | ||||||||
| AuthorizedOfficialFirstName: | VIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3146846750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | 3946 | TN | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 02718770 | 05 | NY | MEDICAID | 035891400 | 05 | DC | MEDICAID | 09753251 | 05 | MS | MEDICAID | 158995407 | 05 | AR | MEDICAID | 188488300 | 05 | MN | MEDICAID | 0578625 | 05 | IA | MEDICAID | 100245100C | 05 | OK | MEDICAID | 1007777870023 | 05 | PA | MEDICAID | 1346208949 | 05 | MT | MEDICAID | 1455112 | 05 | TN | MEDICAID | 160980000 | 05 | ME | MEDICAID | 2093994 | 01 | PK | OTHER | 21460 | 05 | ND | MEDICAID | 99102048 | 05 | NM | MEDICAID | 200445 | 05 | IN | MEDICAID | 200494710A | 05 | IN | MEDICAID | 6027692 | 05 | WA | MEDICAID | 8533812 | 05 | SD | MEDICAID | 010234417 | 05 | VA | MEDICAID | 0103012 | 05 | NJ | MEDICAID | 4094506-00 | 05 | MD | MEDICAID | 927957 | 05 | AZ | MEDICAID | PH536TN | 05 | AK | MEDICAID | 0102997 | 05 | NJ | MEDICAID | 09824589 | 05 | MS | MEDICAID | 2487385 | 05 | OH | MEDICAID | 54008214 | 05 | KY | MEDICAID | 603030503 | 05 | MO | MEDICAID | 113194005 | 05 | WY | MEDICAID | 508187 | 05 | HI | MEDICAID | 30703864 | 05 | NH | MEDICAID | 4436920 | 05 | MI | MEDICAID | 806981800 | 05 | ID | MEDICAID | 8095002 | 05 | WA | MEDICAID |