Provider Demographics
NPI:1629359211
Name:TUCKER, RYAN (RPH)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 CUGGIONO PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3144
Mailing Address - Country:US
Mailing Address - Phone:314-795-5684
Mailing Address - Fax:
Practice Address - Street 1:5023 CUGGIONO PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3144
Practice Address - Country:US
Practice Address - Phone:314-795-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007843183500000X
TX49918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist