Healthcare Provider Details

I. General information

NPI: 1811923162
Provider Name (Legal Business Name): SCHNUCK MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CARLYLE PLAZA DR
BELLEVILLE IL
62221-6678
US

IV. Provider business mailing address

11420 LACKLAND RD
SAINT LOUIS MO
63146-3559
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-8097
  • Fax: 618-234-8199
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number05412053
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number05412053
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LISA DOBBS
Title or Position: MGR 3RD PARTY CLAIMS
Credential:
Phone: 314-994-4902