Healthcare Provider Details

I. General information

NPI: 1134605017
Provider Name (Legal Business Name): IRENE SANSOUCIE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 BUTLER HILL RD
SAINT LOUIS MO
63128-3717
US

IV. Provider business mailing address

123 HARBOR CT
FENTON MO
63026-7516
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-2484
  • Fax: 314-894-2591
Mailing address:
  • Phone: 314-398-1198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2011026615
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: