=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790844173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT KIENTZLE PHARM IN CHARGE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9628 MIDLAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63114-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-423-2000
-----------------------------------------------------
Fax | 314-429-7704
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9628 MIDLAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63114-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-423-2000
-----------------------------------------------------
Fax | 314-429-7704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 41001
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------