Provider Demographics
NPI:1134095185
Name:BOSSUNG, MARY KATHLEEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:BOSSUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:314-251-6048
Mailing Address - Fax:
Practice Address - Street 1:8450 EAGER RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1413
Practice Address - Country:US
Practice Address - Phone:314-962-9036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021027066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist