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General NPI Number Information
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NPI Number | 1205107778
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Entity Type | Individual
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Provider Name | MR. GREGORY D MUDD
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Gender | Male
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Dates
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Enumeration Date | 01/15/2012
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Last Update Date | 01/15/2012
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Provider Practice Location Address
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Address Line | 630 N MCKNIGHT RD
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City | SAINT LOUIS
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State | MO
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Zip | 63132-4911
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Country | US
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Telephone | 314-991-3402
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Fax |
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Provider Business Mailing Address
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Address Line | 7900 GANNON AVE
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City | UNIVERSITY CITY
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State | MO
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Zip | 63130-3707
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 29144
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH30847
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License Number State | CA
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