Healthcare Provider Details

I. General information

NPI: 1104176726
Provider Name (Legal Business Name): JANE TENNIS RPH, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 BOULDER RIVER DR
O FALLON MO
63368-9666
US

IV. Provider business mailing address

4801 WELDON SPRING PKWY
WELDON SPRING MO
63304-9101
US

V. Phone/Fax

Practice location:
  • Phone: 314-651-4716
  • Fax:
Mailing address:
  • Phone: 636-441-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0283146
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: