Provider Demographics
NPI:1700490869
Name:RYBOLT, DAVID ALEXANDER
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALEXANDER
Last Name:RYBOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-1310
Mailing Address - Country:US
Mailing Address - Phone:573-421-0982
Mailing Address - Fax:
Practice Address - Street 1:3822 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1817
Practice Address - Country:US
Practice Address - Phone:314-773-1384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019033541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist