Provider Demographics
NPI:1801439971
Name:SIEDLE, MALORY (PHARMD)
Entity type:Individual
Prefix:
First Name:MALORY
Middle Name:
Last Name:SIEDLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SHORTLEAF PINE DR
Mailing Address - Street 2:
Mailing Address - City:COTTLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7610
Mailing Address - Country:US
Mailing Address - Phone:636-359-3708
Mailing Address - Fax:
Practice Address - Street 1:4700 N HANLEY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-2700
Practice Address - Country:US
Practice Address - Phone:866-997-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist