Healthcare Provider Details

I. General information

NPI: 1679848618
Provider Name (Legal Business Name): MARK SLY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number051295174
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: