Healthcare Provider Details

I. General information

NPI: 1578562831
Provider Name (Legal Business Name): WRYMARK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11833 WESTLINE INDUSTRIAL DR
SAINT LOUIS MO
63146-3312
US

IV. Provider business mailing address

11833 WESTLINE INDUSTRIAL DR
SAINT LOUIS MO
63146-3312
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-3891
  • Fax: 314-991-5720
Mailing address:
  • Phone: 314-991-3891
  • Fax: 314-991-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. L. CHURCHILL MATTHEWS JR.
Title or Position: PRESIDENT/CEO
Credential:
Phone: 314-991-3891