MEDICARE: MRS. CHARLENE M HEYDE

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	183500000X	Pharmacist	030046	MO

General Provider Information

NPI Number	:	1538207964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARLENE M HEYDE

Provider Business Mailing Address
First Line	:	1565 POND RD
Second Line	:
City	:	GLENCOE
State	:	MO
Zip	:	63038-1330
Country	:	US
Telephone Number	:	636-405-7114
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 WEDGEWAY CT
Second Line	:
City	:	EARTH CITY
State	:	MO
Zip	:	63045-1213
Country	:	US
Telephone Number	:	314-291-1122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	07/08/2007

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