Provider Demographics
NPI:1760511075
Name:HILDEBRANDT, JERRY VANCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:VANCE
Last Name:HILDEBRANDT
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 1:479 DOLLY DR
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1611
Mailing Address - Country:US
Mailing Address - Phone:815-468-6330
Mailing Address - Fax:815-468-7995
Practice Address - Street 1:401 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2934
Practice Address - Country:US
Practice Address - Phone:815-935-4356
Practice Address - Fax:815-935-4358
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV09190183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist