Healthcare Provider Details

I. General information

NPI: 1922799212
Provider Name (Legal Business Name): ROBERT OBRADOVIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 LEMAY FERRY RD
SAINT LOUIS MO
63125-1508
US

IV. Provider business mailing address

651 LEMAY FERRY RD
SAINT LOUIS MO
63125-1508
US

V. Phone/Fax

Practice location:
  • Phone: 314-631-4769
  • Fax:
Mailing address:
  • Phone: 314-631-4769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2022025235
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: