Provider Demographics
NPI:1639452352
Name:FIELDS, JEFFREY (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:FIELDS
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 1:2510 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-2323
Mailing Address - Country:US
Mailing Address - Phone:618-875-5085
Mailing Address - Fax:618-875-7434
Practice Address - Street 1:2510 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-2323
Practice Address - Country:US
Practice Address - Phone:618-875-5085
Practice Address - Fax:618-875-7434
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.289087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist