Healthcare Provider Details

I. General information

NPI: 1497668776
Provider Name (Legal Business Name): ELICIA MALAK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 HOMESTEAD VALLEY DR
WILDWOOD MO
63005-8447
US

IV. Provider business mailing address

1409 HOMESTEAD VALLEY DR
WILDWOOD MO
63005-8447
US

V. Phone/Fax

Practice location:
  • Phone: 636-346-3121
  • Fax:
Mailing address:
  • Phone: 636-346-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP460288
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2024033436
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: