Healthcare Provider Details

I. General information

NPI: 1992894661
Provider Name (Legal Business Name): DIERBERGS MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12420 TESSON FERRY RD
SAINT LOUIS MO
63128-2702
US

IV. Provider business mailing address

PO BOX 1070
CHESTERFIELD MO
63006-1070
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-3880
  • Fax: 636-530-3001
Mailing address:
  • Phone: 636-812-1470
  • Fax: 636-812-1603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number005302
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREGORY GUENTHER
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 636-812-1470