Provider Demographics
NPI:1801613922
Name:DEISENROTH, GERARD
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:
Last Name:DEISENROTH
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 1:2730 TOWNE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-4968
Mailing Address - Country:US
Mailing Address - Phone:314-324-8584
Mailing Address - Fax:
Practice Address - Street 1:2730 TOWNE OAKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-4968
Practice Address - Country:US
Practice Address - Phone:314-324-8584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist