Provider Demographics
NPI:1881273506
Name:HAGEDORN, AVERY (PHARMD)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1046
Mailing Address - Country:US
Mailing Address - Phone:314-243-7809
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHLANDS BOULEVARD DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63011-4385
Practice Address - Country:US
Practice Address - Phone:636-868-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010037351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010037351OtherMISSOURI BOARD OF PHARMACY