Basic Information
| Provider Information | |||||||||
| NPI: | 1790848851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE SHARPE | ||||||||
| FirstName: | IVY ANN | ||||||||
| MiddleName: | DESIREE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASE | ||||||||
| OtherFirstName: | IVY ANN | ||||||||
| OtherMiddleName: | DESIREE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Practice Location | |||||||||
| Address1: | 5471 DR MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631124265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143675820 | ||||||||
| FaxNumber: | 3143677010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 029980 | MO | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.