Healthcare Provider Details

I. General information

NPI: 1639787328
Provider Name (Legal Business Name): JUSTIN CLARKE LIEDKE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2020
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JASON DR
TROY MO
63379-1944
US

IV. Provider business mailing address

1172 WARM WINDS DR
O FALLON MO
63366-6305
US

V. Phone/Fax

Practice location:
  • Phone: 636-462-5901
  • Fax:
Mailing address:
  • Phone: 636-697-4904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2020018825
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: