Healthcare Provider Details

I. General information

NPI: 1326524356
Provider Name (Legal Business Name): JONATHON MAUST PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
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

1708 SAINT ANDREWS DR
SHILOH IL
62269-2946
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2013029813
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: