Provider Demographics
NPI:1497355622
Name:MASTERS, RYAN EDWIN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWIN
Last Name:MASTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9122
Mailing Address - Country:US
Mailing Address - Phone:217-228-2331
Mailing Address - Fax:217-228-2339
Practice Address - Street 1:5211 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9122
Practice Address - Country:US
Practice Address - Phone:217-228-2331
Practice Address - Fax:217-228-2339
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist