Provider Demographics
NPI:1538258207
Name:DIERBERGS MARKETS, INCORPORATED
Entity type:Organization
Organization Name:DIERBERGS MARKETS, INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GUENTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-812-1472
Mailing Address - Street 1:450 OLD SMIZER MILL RD.
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026
Mailing Address - Country:US
Mailing Address - Phone:636-349-2666
Mailing Address - Fax:636-530-3018
Practice Address - Street 1:450 OLD SMIZER MILL RD.
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-349-2666
Practice Address - Fax:636-530-3018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIERBERGS MARKETS, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158538333600000X
3336C0003X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2633584OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO605711704Medicaid
MO0580710012Medicare NSC
0580710012Medicare ID - Type Unspecified