Basic Information
| Provider Information | |||||||||
| NPI: | 1710359484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIERBERGS TOWN CENTER PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 TAYLOR ROAD | ||||||||
| Address2: | |||||||||
| City: | WILDWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364587450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2460 TAYLOR ROAD | ||||||||
| Address2: | |||||||||
| City: | WILDWOOD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364587450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2015 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCDANIEL | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STAFF PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 6364587450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 2003031656 | MO | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 606120103 | 05 | MO | MEDICAID |