Provider Demographics
NPI:1073947479
Name:WESSELMANN, TARA L
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:WESSELMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8931 SPRINGDALE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8931 SPRINGDALE AVE
Practice Address - Street 2:STE A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-2400
Practice Address - Country:US
Practice Address - Phone:800-332-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist