Basic Information
| Provider Information | |||||||||
| NPI: | 1972710176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCREDO HEALTH GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACCREDO HEALTH GROUP INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 3000 ERICSSON DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WARRENDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150866501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247726000 | ||||||||
| FaxNumber: | 7247422450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERINI | ||||||||
| AuthorizedOfficialFirstName: | VIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3146846924 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 333600000X | PP415423L | PA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1000016072 | 05 | DE | MEDICAID | 100245550A | 05 | OK | MEDICAID | 100245550B | 05 | OK | MEDICAID | 1007777870026 | 05 | PA | MEDICAID | 200393 | 05 | IN | MEDICAID | 2094317 | 05 | OH | MEDICAID | 21285 | 05 | ND | MEDICAID | 334178 | 05 | AZ | MEDICAID | 500400001 | 05 | OR | MEDICAID | PPA99169 | 05 | PA | MEDICAID | 0514166 | 05 | IA | MEDICAID | 1008681 | 05 | VT | MEDICAID | 200073250A | 05 | IN | MEDICAID | 223504800 | 05 | MD | MEDICAID | 4582531 | 05 | TN | MEDICAID | 9025743700 | 05 | KY | MEDICAID | 003097591 | 05 | CT | MEDICAID | 2081968 | 01 | PK | OTHER | 500400005 | 05 | OR | MEDICAID | 321404400 | 05 | MD | MEDICAID | 4042714 | 05 | TN | MEDICAID | 0014699 | 05 | NJ | MEDICAID | 018650500 | 05 | DC | MEDICAID | 1417915653 | 05 | MT | MEDICAID | 160980002 | 05 | ME | MEDICAID | 71979760 | 05 | NM | MEDICAID | 0007345000 | 05 | WV | MEDICAID | 0014681 | 05 | NJ | MEDICAID | 165745 | 05 | OR | MEDICAID | 508187 | 05 | HI | MEDICAID | 54034285 | 05 | KY | MEDICAID | 6021851 | 05 | WA | MEDICAID | 7331515 | 05 | WA | MEDICAID | 7P5423 | 05 | SC | MEDICAID | OH24981 | 05 | RI | MEDICAID | 003140233 | 05 | CT | MEDICAID | 134364741 | 05 | AR | MEDICAID | 325318000 | 05 | MN | MEDICAID | 62246 | 05 | NM | MEDICAID | 7397489 | 05 | PA | MEDICAID | 9117784 | 05 | VA | MEDICAID | 02364978 | 05 | NY | MEDICAID | 034336100 | 05 | DC | MEDICAID | 5601857 | 05 | MT | MEDICAID | 8517690 | 05 | VA | MEDICAID | DM1235 | 05 | SC | MEDICAID | PH235PA | 05 | AK | MEDICAID |