Healthcare Provider Details

I. General information

NPI: 1134668445
Provider Name (Legal Business Name): MISSOURI LTC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 MANUFACTURERS DR
FENTON MO
63026-2838
US

IV. Provider business mailing address

1617 MANUFACTURERS DR
FENTON MO
63026-2838
US

V. Phone/Fax

Practice location:
  • Phone: 314-690-4500
  • Fax: 314-690-4502
Mailing address:
  • Phone: 314-690-4500
  • Fax: 314-690-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JANICE CERIOTTI
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 314-690-4500