Provider Demographics
NPI:1578869228
Name:MCCOLLUM, JAMES RICHARD (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RICHARD
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1034
Mailing Address - Country:US
Mailing Address - Phone:618-927-4466
Mailing Address - Fax:
Practice Address - Street 1:1102 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1034
Practice Address - Country:US
Practice Address - Phone:618-927-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist