Provider Demographics
NPI:1508143934
Name:FETTER, TRISTA (PHARM D)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:FETTER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 ZUMBEHL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:636-723-1134
Mailing Address - Fax:636-723-0194
Practice Address - Street 1:1780 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303
Practice Address - Country:US
Practice Address - Phone:636-723-1134
Practice Address - Fax:636-723-0194
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist