Provider Demographics
NPI:1144709528
Name:BIONDO, BRYANT
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:BIONDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12938 MADSEN LN
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4339
Mailing Address - Country:US
Mailing Address - Phone:636-208-2364
Mailing Address - Fax:
Practice Address - Street 1:12921 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1206
Practice Address - Country:US
Practice Address - Phone:314-344-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist