Healthcare Provider Details

I. General information

NPI: 1255615126
Provider Name (Legal Business Name): JESSICA MARIN PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LINDELL
SAINT LOUIS MO
63108
US

IV. Provider business mailing address

2330 SULPHUR AVE
SAINT LOUIS MO
63139-2830
US

V. Phone/Fax

Practice location:
  • Phone: 314-371-4286
  • Fax:
Mailing address:
  • Phone: 262-751-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051295339
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2011026598
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: