Provider Demographics
NPI:1316214539
Name:DISTERHOFT, ANGELICA AURORA (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:AURORA
Last Name:DISTERHOFT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 S OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1937
Mailing Address - Country:US
Mailing Address - Phone:309-944-3784
Mailing Address - Fax:309-944-2768
Practice Address - Street 1:1009 S OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1937
Practice Address - Country:US
Practice Address - Phone:309-944-3784
Practice Address - Fax:309-944-2768
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290198183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist