Healthcare Provider Details

I. General information

NPI: 1104739341
Provider Name (Legal Business Name): JIAJING WANG
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PLZ
LAKE ST LOUIS MO
63367-1366
US

IV. Provider business mailing address

31202 POMME DE TERRE DR
LAKE ST LOUIS MO
63367-2170
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2026043760
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: