Provider Demographics
NPI:1952788341
Name:GOLLON, ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GOLLON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:IL
Mailing Address - Zip Code:62075-1657
Mailing Address - Country:US
Mailing Address - Phone:217-563-2701
Mailing Address - Fax:217-563-8337
Practice Address - Street 1:116 W STATE ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075-1657
Practice Address - Country:US
Practice Address - Phone:217-563-2701
Practice Address - Fax:217-563-8337
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371329894001Medicaid