Provider Demographics
NPI:1689272031
Name:BARNEWOLT, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:BARNEWOLT
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 1:13225 N KELSTADT RD
Mailing Address - Street 2:
Mailing Address - City:BRIMFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61517-9651
Mailing Address - Country:US
Mailing Address - Phone:309-635-0621
Mailing Address - Fax:
Practice Address - Street 1:3525 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1324
Practice Address - Country:US
Practice Address - Phone:855-476-5837
Practice Address - Fax:309-280-6045
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05136625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist