Provider Demographics
NPI:1003418971
Name:BORNTREGER, SCOTT (RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BORNTREGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62615-9784
Mailing Address - Country:US
Mailing Address - Phone:217-438-6141
Mailing Address - Fax:
Practice Address - Street 1:620 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615-9784
Practice Address - Country:US
Practice Address - Phone:217-438-6141
Practice Address - Fax:217-438-3447
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist