Provider Demographics
NPI:1083999676
Name:JEDDY, MUSADIQ (RPH)
Entity Type:Individual
Prefix:MR
First Name:MUSADIQ
Middle Name:
Last Name:JEDDY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15308 NOONING TREE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2482
Mailing Address - Country:US
Mailing Address - Phone:636-675-3452
Mailing Address - Fax:
Practice Address - Street 1:15846 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2208
Practice Address - Country:US
Practice Address - Phone:636-527-5074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029516183500000X
AZS018727183500000X
TX58060183500000X
IL051-031888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist