Provider Demographics
NPI:1700160710
Name:JAEGER, MARK J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:JAEGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2540
Mailing Address - Country:US
Mailing Address - Phone:314-771-2900
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-771-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040439183500000X
IL051.292364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist