Provider Demographics
NPI:1649434606
Name:RUSERT, MIRIAM A (RPH)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:A
Last Name:RUSERT
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 1:1203 SMIZER MILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3483
Mailing Address - Country:US
Mailing Address - Phone:636-717-1491
Mailing Address - Fax:636-717-1492
Practice Address - Street 1:1203 SMIZER MILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3483
Practice Address - Country:US
Practice Address - Phone:636-717-1491
Practice Address - Fax:636-717-1492
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist