Healthcare Provider Details

I. General information

NPI: 1104331610
Provider Name (Legal Business Name): SCHNUCK MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 PAGE SERVICE DR STE 101B
SAINT LOUIS MO
63146-3531
US

IV. Provider business mailing address

11420 LACKLAND RD
SAINT LOUIS MO
63146-3559
US

V. Phone/Fax

Practice location:
  • Phone: 314-218-3321
  • Fax: 314-218-3332
Mailing address:
  • Phone: 314-994-4902
  • Fax: 314-994-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LISA M DOBBS
Title or Position: MANAGER OF THIRD PARTY
Credential:
Phone: 314-994-4902