Provider Demographics
NPI:1821616459
Name:ANTONACCI, ROBERT MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARK
Last Name:ANTONACCI
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 1:1919 W PIONEER PKWY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1825
Mailing Address - Country:US
Mailing Address - Phone:309-692-0045
Mailing Address - Fax:309-692-2869
Practice Address - Street 1:1919 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1825
Practice Address - Country:US
Practice Address - Phone:309-692-0045
Practice Address - Fax:309-692-2869
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist