Provider Demographics
NPI:1225021991
Name:PIERCE, CHARLES ALVIN
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ALVIN
Last Name:PIERCE
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 1:423 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-9128
Mailing Address - Country:US
Mailing Address - Phone:309-441-6469
Mailing Address - Fax:
Practice Address - Street 1:423 RIDGE DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-9128
Practice Address - Country:US
Practice Address - Phone:309-441-6469
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist