MEDICARE: DIERBERGS MARKETS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	005052	MO
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2626022	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1184713851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIERBERGS MARKETS INC

Provider Business Mailing Address
First Line	:	PO BOX 1070
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63006-1070
Country	:	US
Telephone Number	:	636-812-1470
Fax Number	:	636-812-1603

Provider Business Practice Location Address
First Line	:	5640 TELEGRAPH RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-4243
Country	:	US
Telephone Number	:	314-846-5778
Fax Number	:	636-530-3014

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	GREGORY GUENTHER
Credential	:
Telephone Number	:	636-812-1470

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	01/30/2009

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Directions to “DIERBERGS MARKETS INC ” Practice Location

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