Provider Demographics
NPI:1467667485
Name:PENCE, REX A (BSPHARM)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:A
Last Name:PENCE
Suffix:
Gender:M
Credentials:BSPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4208
Mailing Address - Country:US
Mailing Address - Phone:309-706-8914
Mailing Address - Fax:
Practice Address - Street 1:1034 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9767
Practice Address - Country:US
Practice Address - Phone:815-842-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist