Provider Demographics
NPI:1083056162
Name:JOHN, JISHA M (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JISHA
Middle Name:M
Last Name:JOHN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2078
Mailing Address - Country:US
Mailing Address - Phone:309-691-5514
Mailing Address - Fax:309-691-5639
Practice Address - Street 1:1919 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1825
Practice Address - Country:US
Practice Address - Phone:309-692-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist