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General NPI Number Information
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NPI Number | 1740766955
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Entity Type | Individual
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Provider Name | JENNIFER L MUDRICK
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Gender | Female
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 07/11/2018
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Provider Practice Location Address
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Address Line | 16580 MANCHESTER RD
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City | WILDWOOD
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State | MO
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Zip | 63040-1217
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Country | US
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Telephone | 636-458-9934
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Fax | 636-458-9274
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Provider Business Mailing Address
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Address Line | 16580 MANCHESTER RD
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City | WILDWOOD
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State | MO
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Zip | 63040-1217
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Country | US
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Telephone | 636-458-9934
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Fax | 636-458-9274
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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 | 2009023456
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License Number State | MO
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