Healthcare Provider Details

I. General information

NPI: 1962202036
Provider Name (Legal Business Name): TESSA ANN BUTT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

10101 SHAPFIELD LN
SAINT LOUIS MO
63123-7417
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051.306598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: