Provider Demographics
NPI:1003058371
Name:SSM HEALTH CARE ST LOUIS
Entity Type:Organization
Organization Name:SSM HEALTH CARE ST LOUIS
Other - Org Name:SSM HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:314-989-2588
Mailing Address - Street 1:12266 DEPAUL DR. SUITE 105
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-344-7300
Mailing Address - Fax:314-344-6179
Practice Address - Street 1:12266 DEPAUL DR. SUITE 105
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
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:2009-04-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336M0002X, 3336S0011X
MO20090048623336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119641OtherPK
MO606172302Medicaid