Provider Demographics
NPI:1699114892
Name:BERNSTEIN, MARK RANDALL (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RANDALL
Last Name:BERNSTEIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12595 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6311
Mailing Address - Country:US
Mailing Address - Phone:314-542-2194
Mailing Address - Fax:636-530-3015
Practice Address - Street 1:12595 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6311
Practice Address - Country:US
Practice Address - Phone:314-542-2194
Practice Address - Fax:636-530-3015
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040400183500000X
IL051.038302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist