Provider Demographics
NPI:1639451420
Name:MARSHALL, JON PATRICK (RPH)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:PATRICK
Last Name:MARSHALL
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 1:4912 EDEN CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9254
Mailing Address - Country:US
Mailing Address - Phone:217-553-1621
Mailing Address - Fax:
Practice Address - Street 1:2945 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4024
Practice Address - Country:US
Practice Address - Phone:217-788-5846
Practice Address - Fax:217-788-8128
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.286958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist