Provider Demographics
NPI:1437604089
Name:WILLIS, THERESA (RPH,MBA)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 EDWARDS ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3915
Mailing Address - Country:US
Mailing Address - Phone:618-208-6937
Mailing Address - Fax:618-208-0291
Practice Address - Street 1:2615 EDWARDS ST STE 102
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-3915
Practice Address - Country:US
Practice Address - Phone:618-208-6937
Practice Address - Fax:618-208-0291
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034923183500000X
MO2011015233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist