Provider Demographics
NPI:1639787328
Name:LIEDKE, JUSTIN CLARKE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLARKE
Last Name:LIEDKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 WARM WINDS DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-6305
Mailing Address - Country:US
Mailing Address - Phone:636-697-4904
Mailing Address - Fax:
Practice Address - Street 1:100 JASON DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1944
Practice Address - Country:US
Practice Address - Phone:636-462-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-19
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020018825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist