Provider Demographics
NPI:1811923162
Name:SCHNUCK MARKETS INC
Entity type:Organization
Organization Name:SCHNUCK MARKETS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR 3RD PARTY CLAIMS
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-994-4902
Mailing Address - Street 1:11420 LACKLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 CARLYLE PLAZA DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-6678
Practice Address - Country:US
Practice Address - Phone:618-234-8097
Practice Address - Fax:618-234-8199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCHNUCK MARKETS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO05412053332B00000X
IL05412053333600000X
163WD0400X, 261QM2500X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No333600000XSuppliersPharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1465841OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========267Medicaid
IL0651810056Medicare NSC