Healthcare Provider Details

I. General information

NPI: 1801439971
Provider Name (Legal Business Name): MALORY SIEDLE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N HANLEY RD
SAINT LOUIS MO
63134-2700
US

IV. Provider business mailing address

172 SHORTLEAF PINE DR
COTTLEVILLE MO
63304-7610
US

V. Phone/Fax

Practice location:
  • Phone: 866-997-3688
  • Fax:
Mailing address:
  • Phone: 636-359-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2015025667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: