Healthcare Provider Details

I. General information

NPI: 1790628535
Provider Name (Legal Business Name): BRUCE JACKSON MEADOWS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 DELMAR BLVD
SAINT LOUIS MO
63112-2617
US

IV. Provider business mailing address

13 N BOYLE AVE
SAINT LOUIS MO
63108-2804
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-7848
  • Fax: 314-367-4849
Mailing address:
  • Phone: 314-808-5280
  • Fax: 314-367-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029740
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: