MEDICARE: SCHNUCK MARKETS INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163WD0400X	Diabetes Educator Registered Nurse
2	261QM2500X	Medical Specialty Clinic/Center
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	333600000X	Pharmacy
5	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1235614165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCHNUCK MARKETS INC

Provider Business Mailing Address
First Line	:	11420 LACKLAND RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3559
Country	:	US
Telephone Number	:	314-994-4902
Fax Number	:	314-994-4586

Provider Business Practice Location Address
First Line	:	10634 SAINT CHARLES ROCK RD
Second Line	:
City	:	SAINT ANN
State	:	MO
Zip	:	63074-1619
Country	:	US
Telephone Number	:	314-426-4180
Fax Number	:	314-426-4371

Authorized Official
Title or Position	:	MANAGER OF THIRD PARTY
Name	:	LISA M DOBBS
Credential	:
Telephone Number	:	314-994-4902

Provider Enumeration Date	:	09/26/2018
Last Update Date	:	01/25/2019

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Directions to “SCHNUCK MARKETS INC ” Practice Location

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