Provider Demographics
NPI:1609969880
Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Entity Type:Organization
Organization Name:SSM CARDINAL GLENNON CHILDRENS HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-989-2588
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5683
Practice Address - Fax:314-268-4069
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTHCARE ST. LOUIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006069333600000X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL430718920003Medicaid
MO600155808Medicaid
2614217OtherOTHER ID NUMBER-COMMERCIAL NUMBER