Provider Demographics
NPI:1497341119
Name:SALEM, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SALEM
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 1:4320 CHOUTEAU AVE # 2F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1606
Mailing Address - Country:US
Mailing Address - Phone:314-757-8380
Mailing Address - Fax:
Practice Address - Street 1:530 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2150
Practice Address - Country:US
Practice Address - Phone:636-970-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019045835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist