Provider Demographics
NPI:1629313630
Name:DIERICX, CALEB (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CALEB
Middle Name:
Last Name:DIERICX
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1054
Mailing Address - Country:US
Mailing Address - Phone:309-993-6330
Mailing Address - Fax:
Practice Address - Street 1:1704 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1054
Practice Address - Country:US
Practice Address - Phone:309-993-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY019849183500000X
IL051295840183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist