MEDICARE: DR. KENNETH JOHN BAST PHARMD

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	2009011779	MO

General Provider Information

NPI Number	:	1891070199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH JOHN BAST PHARMD

Provider Business Mailing Address
First Line	:	3923 MCREE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2628
Country	:	US
Telephone Number	:	636-399-1652
Fax Number	:

Provider Business Practice Location Address
First Line	:	2933 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-1008
Country	:	US
Telephone Number	:	314-773-2767
Fax Number	:	314-773-4917

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

Provider Enumeration Date	:	10/18/2011
Last Update Date	:	10/18/2011

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