Provider Demographics
NPI:1568067569
Name:DOUBET, MARK (BSPHARM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DOUBET
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 1:3134 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2273
Mailing Address - Country:US
Mailing Address - Phone:815-398-0048
Mailing Address - Fax:
Practice Address - Street 1:3134 11TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2273
Practice Address - Country:US
Practice Address - Phone:815-398-0048
Practice Address - Fax:815-398-9687
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist