Provider Demographics
NPI:1275019416
Name:BRISTOW, REBECCA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 TROY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2582
Mailing Address - Country:US
Mailing Address - Phone:618-659-0026
Mailing Address - Fax:618-659-0027
Practice Address - Street 1:2222 TROY RD
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2582
Practice Address - Country:US
Practice Address - Phone:618-659-0026
Practice Address - Fax:618-659-0027
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.292678OtherPHARMACIST LICENSE