Provider Demographics
NPI:1093315418
Name:EISELE, DOUGLAS MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:EISELE
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 1:2608 GREEN MOUNT COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-6742
Mailing Address - Country:US
Mailing Address - Phone:618-277-2020
Mailing Address - Fax:618-277-2024
Practice Address - Street 1:2608 GREEN MOUNT COMMONS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-6742
Practice Address - Country:US
Practice Address - Phone:618-277-2020
Practice Address - Fax:618-277-2024
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist