Healthcare Provider Details

I. General information

NPI: 1730792573
Provider Name (Legal Business Name): ELIANNA AXELBAUM PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 08/30/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6733 CLAYTON RD
RICHMOND HEIGHTS MO
63117-1603
US

IV. Provider business mailing address

6733 CLAYTON RD # RX
RICHMOND HEIGHTS MO
63117-1603
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-6013
  • Fax:
Mailing address:
  • Phone: 314-721-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2017031089
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: