Provider Demographics
NPI:1235470725
Name:OLIVARES, JITTARAT C (PHARMD)
Entity Type:Individual
Prefix:
First Name:JITTARAT
Middle Name:C
Last Name:OLIVARES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 LEMAY FERRY
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125
Mailing Address - Country:US
Mailing Address - Phone:314-894-7755
Mailing Address - Fax:
Practice Address - Street 1:2516 LEMAY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3131
Practice Address - Country:US
Practice Address - Phone:314-894-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003000287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist