Provider Demographics
NPI:1760767297
Name:DIERKER, SHANNON (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DIERKER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 CLARKSON CLAYTON CTR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2145
Mailing Address - Country:US
Mailing Address - Phone:636-394-4422
Mailing Address - Fax:
Practice Address - Street 1:1302 CLARKSON CLAYTON CTR
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2145
Practice Address - Country:US
Practice Address - Phone:636-394-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist