Provider Demographics
NPI:1902187677
Name:VIERKE, MARK ANDREW (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:VIERKE
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 1:3213 BERRY ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-1116
Mailing Address - Country:US
Mailing Address - Phone:815-690-5490
Mailing Address - Fax:815-943-4649
Practice Address - Street 1:395 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3258
Practice Address - Country:US
Practice Address - Phone:815-943-4376
Practice Address - Fax:815-943-4649
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist