Provider Demographics
NPI:1023391331
Name:RUPERT, MARIE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:
Last Name:RUPERT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N UNIVERSITY STREET
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-2540
Mailing Address - Country:US
Mailing Address - Phone:309-438-8713
Mailing Address - Fax:309-438-7569
Practice Address - Street 1:201 N UNIVERSITY STREET
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790
Practice Address - Country:US
Practice Address - Phone:309-438-8713
Practice Address - Fax:309-438-7569
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL051.292018OtherIL PHARMACY LICENSE NO.