Provider Demographics
NPI:1598877961
Name:BLACK, ERIC LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 PACE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2834
Mailing Address - Country:US
Mailing Address - Phone:618-614-5505
Mailing Address - Fax:618-242-0424
Practice Address - Street 1:2339 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2925
Practice Address - Country:US
Practice Address - Phone:618-242-8776
Practice Address - Fax:618-242-0424
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371268476001Medicaid
IL371268476001Medicaid