Provider Demographics
NPI:1033209077
Name:DIERBERGS MARKETS INC
Entity Type:Organization
Organization Name:DIERBERGS MARKETS INC
Other - Org Name:DIERBERGS EDWARDSVILLE CROSSING PHARMACY
Other - Org Type:Doing Business As
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 1:6671 EDWARDSVILLE CROSSING DRIVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-307-3817
Practice Address - Fax:618-307-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54015911333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1480071OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========002Medicaid
1480071OtherOTHER ID NUMBER-COMMERCIAL NUMBER