Healthcare Provider Details

I. General information

NPI: 1053533018
Provider Name (Legal Business Name): RYAN WESLEY RINEY R. PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 GRAVOIS
ST. LOUIS MO
63116
US

IV. Provider business mailing address

9010 MAPLE RD
EDWARDSVILLE IL
62025
US

V. Phone/Fax

Practice location:
  • Phone: 314-771-0218
  • Fax: 314-771-4862
Mailing address:
  • Phone: 618-633-2580
  • Fax: 314-771-4862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2004031545
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: