Provider Demographics
NPI:1568747194
Name:BIRKENKAMP, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:BIRKENKAMP
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 1:13423 THORNHILL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1627
Mailing Address - Country:US
Mailing Address - Phone:314-965-0393
Mailing Address - Fax:
Practice Address - Street 1:1391 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7616
Practice Address - Country:US
Practice Address - Phone:636-861-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000168504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist