Provider Demographics
NPI:1437276458
Name:GERGEN, SHANNON SCOTT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:SCOTT
Last Name:GERGEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKINGS DR
Mailing Address - Street 2:CAMPUS BOX 1201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4862
Mailing Address - Country:US
Mailing Address - Phone:314-935-6662
Mailing Address - Fax:
Practice Address - Street 1:6643 SHEPLEY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-2354
Practice Address - Country:US
Practice Address - Phone:314-935-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005012074183500000X
IL051.290355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist