Provider Demographics
NPI:1073730859
Name:DEMARET, RALPH
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:
Last Name:DEMARET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 381
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-9528
Mailing Address - Country:US
Mailing Address - Phone:618-842-3209
Mailing Address - Fax:618-375-2131
Practice Address - Street 1:110 E NORTH ST
Practice Address - Street 2:
Practice Address - City:GRAYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62844-1402
Practice Address - Country:US
Practice Address - Phone:618-375-2131
Practice Address - Fax:618-375-5029
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051029153OtherSTATE LICENSE NUMBER