Provider Demographics
NPI:1255096079
Name:AYRESBENNETT, ANGELIA LEIGH
Entity type:Individual
Prefix:
First Name:ANGELIA
Middle Name:LEIGH
Last Name:AYRESBENNETT
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 1:601 N COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-3327
Mailing Address - Country:US
Mailing Address - Phone:618-252-8691
Mailing Address - Fax:618-252-7602
Practice Address - Street 1:601 N COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3327
Practice Address - Country:US
Practice Address - Phone:618-252-8691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0369931835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist