Provider Demographics
NPI:1598366429
Name:HERSCHBACH, LEANN
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:HERSCHBACH
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 1:1040 COLLINSVILLE CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1882
Mailing Address - Country:US
Mailing Address - Phone:618-344-7112
Mailing Address - Fax:618-344-7003
Practice Address - Street 1:1040 COLLINSVILLE CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234
Practice Address - Country:US
Practice Address - Phone:618-344-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.039843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist