Provider Demographics
NPI:1477164473
Name:RENNECKER, ROBERT KOERT (BS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KOERT
Last Name:RENNECKER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16059 E CR 900N
Mailing Address - Street 2:
Mailing Address - City:KILBOURNE
Mailing Address - State:IL
Mailing Address - Zip Code:62655-6541
Mailing Address - Country:US
Mailing Address - Phone:309-256-2951
Mailing Address - Fax:
Practice Address - Street 1:555 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-1829
Practice Address - Country:US
Practice Address - Phone:309-647-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist