Healthcare Provider Details

I. General information

NPI: 1194637710
Provider Name (Legal Business Name): REBECCA WAKELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4108
US

IV. Provider business mailing address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4108
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax: 636-933-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2026035343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: