Healthcare Provider Details

I. General information

NPI: 1316929599
Provider Name (Legal Business Name): GENESIS ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1876 CRAIGSHIRE RD
SAINT LOUIS MO
63146-4006
US

IV. Provider business mailing address

1876 CRAIGSHIRE RD
SAINT LOUIS MO
63146-4006
US

V. Phone/Fax

Practice location:
  • Phone: 314-485-8600
  • Fax: 314-485-1049
Mailing address:
  • Phone: 855-485-8600
  • Fax: 314-485-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2014004392
License Number StateMO

VIII. Authorized Official

Name: FRANK MANION
Title or Position: OWNER
Credential:
Phone: 314-485-8600