Healthcare Provider Details

I. General information

NPI: 1700363801
Provider Name (Legal Business Name): ROBERT BUGANSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 LACKLAND RD
SAINT LOUIS MO
63146-3561
US

IV. Provider business mailing address

11420 LACKLAND RD
SAINT LOUIS MO
63146-3561
US

V. Phone/Fax

Practice location:
  • Phone: 314-994-2225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045156
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: