Provider Demographics
NPI:1760762496
Name:FISHER, JEROME MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:MICHAEL
Last Name:FISHER
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 1:673 OLD TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1303
Mailing Address - Country:US
Mailing Address - Phone:847-814-1071
Mailing Address - Fax:
Practice Address - Street 1:8361 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171-1001
Practice Address - Country:US
Practice Address - Phone:708-452-8062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5128746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist