Provider Demographics
NPI:1417547571
Name:RAPP, TARA DENISE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DENISE
Last Name:RAPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19851 STATE ROUTE 177
Mailing Address - Street 2:
Mailing Address - City:HOYLETON
Mailing Address - State:IL
Mailing Address - Zip Code:62803-1903
Mailing Address - Country:US
Mailing Address - Phone:618-406-2515
Mailing Address - Fax:
Practice Address - Street 1:1 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2402
Practice Address - Country:US
Practice Address - Phone:618-899-3426
Practice Address - Fax:618-899-4736
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist