Provider Demographics
NPI:1437797255
Name:ALSUP, KATHLEEN MARY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:ALSUP
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 1:4700 N HANLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-2700
Mailing Address - Country:US
Mailing Address - Phone:866-997-3688
Mailing Address - Fax:866-470-1744
Practice Address - Street 1:4700 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-2700
Practice Address - Country:US
Practice Address - Phone:866-997-3688
Practice Address - Fax:866-470-1744
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007036871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist