Provider Demographics
NPI:1881170967
Name:FISHERKELLER, GAIL ANN
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:ANN
Last Name:FISHERKELLER
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 1:8726 CARBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7898
Mailing Address - Country:US
Mailing Address - Phone:815-871-0633
Mailing Address - Fax:
Practice Address - Street 1:6410 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3008
Practice Address - Country:US
Practice Address - Phone:815-397-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist