Provider Demographics
NPI:1629355094
Name:MCDANEL, THERESA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:MCDANEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 TROY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2540
Mailing Address - Country:US
Mailing Address - Phone:618-655-0386
Mailing Address - Fax:618-655-0394
Practice Address - Street 1:2122 TROY RD
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2540
Practice Address - Country:US
Practice Address - Phone:618-655-0386
Practice Address - Fax:618-655-0394
Is Sole Proprietor?:No
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292828183500000X
MO2008028030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist