Provider Demographics
NPI:1487986717
Name:KOENEN, PEGGY A (RPH)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:KOENEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 GRAVOIS VILLAGE CTR
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-1838
Mailing Address - Country:US
Mailing Address - Phone:636-376-5000
Mailing Address - Fax:636-677-1870
Practice Address - Street 1:4560 GRAVOIS VILLAGE CTR
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-1838
Practice Address - Country:US
Practice Address - Phone:636-376-5000
Practice Address - Fax:636-677-1870
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist