Provider Demographics
NPI:1093131732
Name:PERRY, TODD (RPH)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:PERRY
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 1:1075 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1545
Mailing Address - Country:US
Mailing Address - Phone:309-263-2313
Mailing Address - Fax:309-263-2616
Practice Address - Street 1:1075 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-1545
Practice Address - Country:US
Practice Address - Phone:309-263-2313
Practice Address - Fax:309-263-2616
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051039578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist