Provider Demographics
NPI:1720866593
Name:NESTLEROAD, COLLIN JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:JACOB
Last Name:NESTLEROAD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 FIELD CROSSING DR APT 14
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-3966
Mailing Address - Country:US
Mailing Address - Phone:618-292-3444
Mailing Address - Fax:
Practice Address - Street 1:1401 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1028
Practice Address - Country:US
Practice Address - Phone:618-283-0196
Practice Address - Fax:618-283-9150
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist