Provider Demographics
NPI:1992894661
Name:DIERBERGS MARKETS INC
Entity type:Organization
Organization Name:DIERBERGS MARKETS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUENTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-812-1470
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-1070
Mailing Address - Country:US
Mailing Address - Phone:636-812-1470
Mailing Address - Fax:636-812-1603
Practice Address - Street 1:12420 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2702
Practice Address - Country:US
Practice Address - Phone:314-849-3880
Practice Address - Fax:636-530-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MO005302333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2627531OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO603681404Medicaid
0580710006Medicare ID - Type Unspecified
MO603681404Medicaid