Healthcare Provider Details

I. General information

NPI: 1083190045
Provider Name (Legal Business Name): MICHELLE SPOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12921 ENTERPRISE WAY
BRIDGETON MO
63044-1206
US

IV. Provider business mailing address

5200 SUNDROP CT
GODFREY IL
62035-1691
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-9604
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2010005641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: