Provider Demographics
NPI:1710076484
Name:DIERBERGS MARKETS INC
Entity Type:Organization
Organization Name:DIERBERGS MARKETS INC
Other - Org Name:DIERBERGS 94 CROSSING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUENTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-812-1470
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-1070
Mailing Address - Country:US
Mailing Address - Phone:636-812-1470
Mailing Address - Fax:636-812-1603
Practice Address - Street 1:6211 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-1102
Practice Address - Country:US
Practice Address - Phone:636-936-3020
Practice Address - Fax:636-530-3016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006054333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2631009OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO608536504Medicaid
MO0580710010Medicare NSC
MO608536504Medicaid