Provider Demographics
NPI:1326470410
Name:INGRAM, RICHARD KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KENNETH
Last Name:INGRAM
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 1:1372 COUNTY ROAD 2275 E
Mailing Address - Street 2:P.O.BOX 588
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:IL
Mailing Address - Zip Code:61873-9627
Mailing Address - Country:US
Mailing Address - Phone:217-469-2007
Mailing Address - Fax:
Practice Address - Street 1:1372 COUNTY ROAD 2275 E
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:IL
Practice Address - Zip Code:61873-9627
Practice Address - Country:US
Practice Address - Phone:217-469-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist