Provider Demographics
NPI:1811264682
Name:SECREST, SANDRA A
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:SECREST
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 1:265 W BOND ST
Mailing Address - Street 2:
Mailing Address - City:BEMENT
Mailing Address - State:IL
Mailing Address - Zip Code:61813-1404
Mailing Address - Country:US
Mailing Address - Phone:217-678-3231
Mailing Address - Fax:
Practice Address - Street 1:302 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-2500
Practice Address - Country:US
Practice Address - Phone:217-344-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051031023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist