Provider Demographics
NPI:1699861674
Name:SSM PHARMACY @ DEPAUL
Entity type:Organization
Organization Name:SSM PHARMACY @ DEPAUL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ARENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:314-344-7300
Mailing Address - Street 1:12255 DE PAUL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2513
Mailing Address - Country:US
Mailing Address - Phone:314-344-7300
Mailing Address - Fax:314-344-6179
Practice Address - Street 1:12255 DE PAUL DR STE 120
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2513
Practice Address - Country:US
Practice Address - Phone:314-344-7300
Practice Address - Fax:314-344-6179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO42638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty