Healthcare Provider Details

I. General information

NPI: 1922384916
Provider Name (Legal Business Name): HEATHER A INGRAM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2011
Last Update Date: 10/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GRASSO PLZ
AFFTON MO
63123-3107
US

IV. Provider business mailing address

1 GRASSO PLZ
AFFTON MO
63123-3107
US

V. Phone/Fax

Practice location:
  • Phone: 314-631-8800
  • Fax: 314-631-8801
Mailing address:
  • Phone: 314-631-8800
  • Fax: 314-631-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044489
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: