Provider Demographics
NPI:1689261018
Name:LANGENFELD, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:LANGENFELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 GRAGG ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-2760
Mailing Address - Country:US
Mailing Address - Phone:618-339-4579
Mailing Address - Fax:618-533-0566
Practice Address - Street 1:1071 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5309
Practice Address - Country:US
Practice Address - Phone:618-532-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist