Healthcare Provider Details

I. General information

NPI: 1629898127
Provider Name (Legal Business Name): LEE DAVID KOHLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7922 MACKENZIE RD
AFFTON MO
63123-2721
US

IV. Provider business mailing address

8640 COMMERCIAL BLVD
PEVELY MO
63070-1529
US

V. Phone/Fax

Practice location:
  • Phone: 314-638-3535
  • Fax:
Mailing address:
  • Phone: 636-479-6100
  • Fax: 636-479-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2024040264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: