Provider Demographics
NPI:1518567114
Name:RICKERT, ANNE AUGUSTINE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:AUGUSTINE
Last Name:RICKERT
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 1:1417 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-1235
Mailing Address - Country:US
Mailing Address - Phone:314-440-4192
Mailing Address - Fax:
Practice Address - Street 1:2610 W HAVEN RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-3345
Practice Address - Country:US
Practice Address - Phone:618-943-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist