Healthcare Provider Details

I. General information

NPI: 1811773591
Provider Name (Legal Business Name): RYAN COOLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 BUTLER HILL RD
SAINT LOUIS MO
63128-3717
US

IV. Provider business mailing address

1686 IRISH SEA
HIGH RIDGE MO
63049-3815
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-2484
  • Fax:
Mailing address:
  • Phone: 314-775-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2023032588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: