Provider Demographics
NPI:1639449515
Name:RENIER, MARK G (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:RENIER
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 1:901 6TH STREET DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-1291
Mailing Address - Country:US
Mailing Address - Phone:309-799-3036
Mailing Address - Fax:
Practice Address - Street 1:901 6TH STREET DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-1291
Practice Address - Country:US
Practice Address - Phone:309-799-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16089183500000X
IL051.289814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist